Critical Care: Chapter 11: Organ Donations

3. The charge nurse is reviewing the status of patients in the critical care unit. Which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic male with a history of unstable angina status post resuscitation

ANS: A A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other patient scenarios.

5. The nurse is caring for a patient who is being evaluated clinically for brain death by a physician. Which assessment findings by the nurse support brain death? a. Absence of a corneal reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8° F

ANS: A Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.

6. The nurse is providing preoperative care to a patient who will receive a transplant. The patient has high panel reactive antibodies (PRA). As part of induction therapy for this patient, the nurse understands which medication to be of priority for administration in the operating room? a. Alemtuzumab (Campath) b. Tacrolimus (Prograf) c. Sirolimus (Rapamune) d. Cyclosporine (Neoral)

ANS: A Alemtuzumab (Campath) is a monoclonal antibody used as an induction agent in patients that are at high immunological risk. Tacrolimus (Prograf), sirolimus (Rapamune), and cyclosporine (Neoral) are all immunosuppressive agents used as part of ongoing maintenance therapy.

19. The transplant clinic nurse is educating a patient about the renal criteria that must be met in order to be placed on the transplant waiting list. Which statement by the patient best indicates an understanding of the criteria? a. "I qualify if my glomerular filtration rate is less than 20 mL per minute." b. "I will not qualify until I have to go on regular hemodialysis treatments." c. "My blood type does not have to be a match with the donor blood type." d. "The national waiting list is based on the ability to pay for medications."

ANS: A Candidates are placed on the UNOS national waiting list once they become dialysis dependent or have a glomerular filtration rate of less than 20 mL/minute if not on dialysis. ABO compatibility is necessary for successful renal transplantation. A point system is used to rank candidates to determine who will receive a kidney when a donor becomes available.

18. The transplant clinic social worker is completing a social history on a patient with end-stage renal disease who is being evaluated for transplant. Which statement by the patient warrants further action? a. "I only smoke marijuana on an occasional basis." b. "I have two sisters who live within two hours of me." c. "I have attended all of my scheduled dialysis sessions." d. "My mother's side of the family has a history of cancer."

ANS: A Current recreational drug use is a contraindication to transplantation. Family support is critical during posttransplant care. Adherence to dialysis indicates likely success in adhering to future treatment plans. A patient history of active or recent malignancy is a contraindication to transplantation.

11. The nurse is caring for a renal transplant recipient in the post-anesthesia care unit. Blood pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula, temperature is 97.8° F, and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse? a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered.

ANS: A Fluid replacement therapy is a priority in a postoperative renal transplant patient with a CVP of 2 mm Hg and elevated heart rate. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is normothermic; application of active warming measures is not indicated. Although pain assessment is an important part of postoperative nursing care, it is not the priority in this scenario.

1. The nurse is working for a hospital that holds an agreement with a local organ procurement organization (OPO). The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation? a. "I need to notify TransLife (OPO) of my patient's impending death." b. "I will contact the physician to obtain informed consent for organ donation." c. "The charge nurse will notify TransLife (OPO) once the patient has been pronounced brain dead." d. "I need the physician to evaluate my patient's suitability for organ donation."

ANS: A Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the physician, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur prior to death, not after the patient has been pronounced dead.

15. While following up on a postoperative renal transplant recipient, the nurse discovers that the donor tested positive for cytomegalovirus (CMV). What is the priority action by the nurse? a. Notify the OPO transplant coordinator. b. Verify results with the lab technician. c. Repeat all pre-procedure viral studies. d. Continue to monitor for signs of rejection.

ANS: A It is mandatory to report any donor-derived infections to the organ procurement organization (OPO). The priority action is to notify the transplant coordinator. Verifying results with the lab technician, if indicated, would be the responsibility of the transplant coordinator. Repeating viral studies and continuing to monitor for signs of rejection are appropriate actions but not the immediate priority.

25. The nurse assesses morning lab results for a postoperative day 1 liver transplant recipient. Lab results noted by the nurse include aspartate transaminase (AST) 365 U/L; alanine aminotransferase (ALT) 400 U/L; and serum glucose of 85 mg/dL. What is the best action by the nurse? a. Notify the physician of liver enzyme results. b. Treat hypoglycemia with 50 mL 5% dextrose. c. Repeat the liver enzyme results in 4 hours. d. Prepare to administer IV insulin infusion.

ANS: A Laboratory values should be trended, but the nurse should notify the physician of the elevated liver enzyme results, as significantly elevated results could indicate hepatic artery thrombosis. Glucose of 85 mg/dL is considered within normal limits by most laboratories and would not require treatment with glucose or insulin to normalize. Repeating the enzyme results in 4 hours would be appropriate, but it is not the immediate priority.

32. Which statement best describes the lung allocation score (LAS) used to prioritize lung transplant recipients? a. The LAS is based on lab values, diagnostic tests, and medical diagnosis. b. Lungs from children and adolescents are offered to adults first. c. The LAS is limited to candidates under the age of 65 years. d. The score was developed to estimate 5-year survival rates.

ANS: A The LAS is based on lab values, diagnostic tests, and medical diagnosis; candidates with higher LASs have higher priority than those with lower scores. Lungs from children and adults are offered to pediatric and adolescent candidates first. The LAS is used for all patients who are listed on the organ donor registry. The LAS was developed to estimate the change of first-year survival after transplantation.

23. The transplant clinic nurse is conducting a pretransplant education session for patients being evaluated for liver transplantation. Which statement by the nurse provides the best explanation of the numeric system used to classify the severity of a patient's liver disease? a. "A score is calculated based upon kidney function, clotting time, and bilirubin levels." b. "A score is calculated that ranges between 6 and 40, with the lower score being more serious." c. "There are currently no exceptions to the MELD score calculation for severity of disease." d. "The calculated score represents the patient's risk of death within 1 year of diagnosis."

ANS: A The Model for End-Stage Liver Disease (MELD) score uses the patient's serum creatinine, international normalized ratio (INR) for prothrombin time, and serum bilirubin to predict survival. Calculated MELD scores range between 6 and 40, with higher scores directly associated with the patient's risk of death in 3 months. Patients with an acute onset of liver disease and a life expectancy of hours to a few days are the only exception to the use of a calculated MELD score. The MELD score measures the severity of liver disease.

22. The nurse is providing postoperative education to a transplant patient's family. When asked about detecting rejection, which answer by the nurse is most appropriate? a. "Endomyocardial biopsies will be performed weekly for the first six weeks after surgery." b. "Increased shortness of breath most likely indicates immediate, acute rejection of the heart." c. "Biopsies of the heart are done every 6 months after the day of the transplant surgery." d. "As time passes, the more biopsies that are performed, the more reliable the results become."

ANS: A The traditional method of rejection surveillance in a heart transplant recipient is through endometrial biopsies performed weekly during the first six weeks posttransplant. Shortness of breath can be a symptom of rejection, but only in combination with other symptoms. Rejection is confirmed through biopsy. Over time, with frequent biopsies, cardiac tissue becomes scarred, making detection of rejection impossible.

1. The family of a critically ill patient has asked to discuss organ donation with the patient's nurse. When preparing to answer the family's questions, the nurse understands which concern(s) most often influence a family's decision to donate? (Select all that apply.) a. Donor disfigurement influences on funeral care b. Fear of inferior medical care provided to donor c. Age and location of all possible organ recipients d. Concern that donated organs will not be used e. Fear that the potential donor may not be deceased f. Concern over financial costs associated with donation

ANS: A, B, E, F Common fears and concerns that can influence a family's decision to donate include fear of disfigurement of the donor, fear of inferior medical care being provided to the donor in order to hasten the process, fear that the donor may not really be deceased, and concern that the family of the donor will assume the financial burden associated with the donation. The number of individuals awaiting transplant along with the current UNOS registry system ensures all procured organs will be transplanted. The age and location of recipients are not disclosed by the OPO.

27. A renal transplant recipient presents to the outpatient transplant clinic with blood glucose values for the past 3 days exceeding 250 mg/dL. The patient takes prednisone 5 mg daily and tacrolimus (Prograf) 2 mg twice daily. Hemoglobin A1C level drawn the day of the clinic appointment was 8.5%. What is the best interpretation of this finding by the nurse? a. The patient is at increased risk for infection. b. The patient has developed posttransplant diabetes. c. Temporary elevations in blood sugars are normal. d. Discontinuation of steroids will normalize values.

ANS: B A patient taking steroids and calcineurin inhibitors is at risk for the development of posttransplant diabetes as a complication of long-term medication therapy. Although the lab values in isolation do not indicate infection, blood sugars must be normalized to promote healing. Hemoglobin A1C levels indicate the level of blood sugar control over the past 2 to 3 months. Findings should not be considered temporary. Although steroids can elevate blood sugar values, discontinuation of steroid therapy may not be feasible in all transplant recipients.

28. The postanesthesia care unit receives handoff communication from the CRNA indicating that the renal transplant recipient received induction therapy in the operating room with antithymocyte globulin (ATG). What is the best understanding of the administration of this drug by the nurse? a. The drug is administered for recipients of CMV-positive donor organs. b. Administration of the drug decreases initial postoperative rejection rates. c. Antiproliferative agents are recommended for routine induction therapy. d. Antithymocyte globulin (ATG) is given as a single dose in the OR.

ANS: B Administration of antiproliferative agents such as antithymocyte globulin (ATG) has been shown to decrease rejection rates in the initial postoperative period. Antiviral agents are administered if CMV donor status is positive. Antiproliferative agents are recommended as first choice for induction therapy in recipients at high immunological risk. ATG is given in the operating room as well as for several days postoperative.

7. The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention? a. Thirty-degree elevation of head of bed b. Endotracheal suctioning as needed c. Frequent side to side repositioning d. Sequential compression stockings

ANS: B Denervation of the lung that occurs during lung transplantation causes changes in mucus production and ciliary movement. As a result, to promote the drainage of secretions and prevent mucus plugging, endotracheal and oral suctioning should be a priority of nursing care in the postoperative lung transplant patient. Head of bed elevation, side to side repositioning, and application of sequential compression stockings are appropriate nursing interventions, but they are not the priority intervention.

2. The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse? a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8° F d. Central venous pressure of 8 mm Hg

ANS: B Donor management, focuses on maintaining hemodynamic stability and normal laboratory parameters. Care of the patient is under the direction of the OPO coordinator working collaboratively with the physician and critical care nurses. Standardized order sets are usually used, and they focus on preserving organ function and viability.Immediate action is required for an arterial blood gas value of pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L which indicates metabolic acidosis. All other values are within normal limits.

13. The nurse is providing discharge instructions to a renal transplant recipient. The patient has a follow-up appointment the next day for routine post-transplant laboratory bloodwork, including trough levels of anti-rejection medications.Which instruction describes what the patient should do regarding the anti-rejection medications the next day? a. "Take your morning dose of medications at midnight with sips of water." b. "Take your morning dose of medications after labs have been drawn." c. "Skip your morning dose of medications and then resume your evening doses." d. "Hold all doses of your medications the day you have labs drawn."

ANS: B Medication trough levels are used to guide dosing. The patient should not take his morning dose of medications until labs have been drawn so that an accurate trough level is obtained. Transplant medication is administered at regular dosing intervals (e.g. every 12 hours) to maintain therapeutic drug levels and intervals should not be independently adjusted. Medication should not be skipped when lab is drawn. The patient should be instructed to take the medication immediately after lab work has been drawn. Medication is not to be held for an entire day as doing so places the patient at risk for rejection.

34. The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The patient asks the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse? a. "Your admission lab results will determine if your kidney is being rejected." b. "A procedure called a renal biopsy will be the best way to confirm rejection." c. "Monitoring over the next few days will determine if your kidney is failing." d. "An ultrasound of your kidney will determine if your kidney has failed."

ANS: B Renal biopsy confirms the presence of rejection. Admission lab results will provide information related to the current functional level of the kidney but will not confirm rejection. Monitoring the patient will not confirm the presence of rejection. An ultrasound of the kidney will determine if there is blood flow to the kidney but will not provide information at the cellular level.

21. The nurse is preparing to admit a patient with heart failure who has been listed on the UNOS transplant list as status 1A. What is the best understanding of this classification by the nurse? a. The patient can be managed at home with a left ventricular assist device. b. Hospitalization is required with mechanical support and vasoactive infusions. c. The patient has advanced heart failure and is being managed with medication. d. An advanced heart failure patient not successfully managed on medications.

ANS: B Status 1A is the most urgent status assigned to advanced heart failure awaiting transplantation. Status 1A patients are expected to die within a week without transplant. Status 1B patients are less urgent and can be managed at home with a left ventricular assist device. A patient with advanced heart failure being managed with medications is being managed appropriately. An advanced heart failure patient not successfully managed on medications has the option of listing for a heart transplant.

16. The transplant clinic nurse is conducting patient education on the importance of follow-up health screening activities important in detecting complications associated with long-term immunosuppressant therapy. Which statement is most important for the nurse to include in the discussion? a. "Application of sunscreen may cause a reaction." b. "Avoid sun exposure during peak hours of the day." c. "Melanoma is the most common type of cancer." d. "Skin examinations should occur every 5 years."

ANS: B The nurse should instruct the patient to avoid sun exposure during peak hours of the day. Application of sunscreen is a priority to reduce the risk of sunburn and subsequent skin cancer. The most common type of skin cancer is squamous cell cancer. Skin examinations should be conducted annually.

12. The nurse is caring for a postoperative renal transplant recipient in the critical care unit. After seeing minimal urine output in the catheter for most of the day, the patient expresses concern to the nurse. What is the best response by the nurse? a. "Your kidney has unfortunately failed and will be removed." b. "It can take a few days for your kidney to start working" c. "You are experiencing an acute rejection episode." d. "You will have to undergo daily hemodialysis treatments."

ANS: B There are many factors that can delay normal functioning of a transplanted renal graft (e.g., prolonged cold times, altered perfusion states during surgery). It can take a few days for the transplant to function optimally. Low urine output alone is not the sole indicator of kidney failure or an acute rejection episode. Hemodialysis treatments are not routine in the presence of low urine output following a renal transplant.

26. The transplant clinic nurse is educating a group of transplant recipients on health promotion and maintenance. What is the priority statement by the nurse? a. "Adhere to all future scheduled appointments with the clinic." b. "Obtain annual vaccinations for pneumonia from your physician." c. "Report all routine lab results to your primary care physician." d. "Notify the transplant clinic of all future hospital admissions."

ANS: B To protect against viruses that would be detrimental to a transplant recipient, it is most important for transplant patients to consult with their clinic providers to obtain the appropriate vaccinations. Adherence to future scheduled appointments, reporting lab results, and notifying the clinic of all future hospitalizations are part of long-term care, but appropriate vaccinations are essential to the health of the patient.

4. The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation? a. A 65-year-old brother with a history of hypertension; blood type A positive b. A 35-year-old female with a history of food allergies; blood type O negative c. A 14-year-old son, otherwise healthy with no history; blood type B negative d. A 70-year-old mother, with a history of sinus infections; blood type A positive

ANS: B To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food allergies; blood type O negative (universal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside of acceptable age ranges for living donation. The minor son does not qualify based on blood type.

24. Which statement best represents appropriate donor-to-recipient criteria for liver transplantation? a. Blood type and HLA tissue type b. HLA tissue type and body type c. Body type and body size d. Blood type and donor history

ANS: C Blood type and body size are the two criteria necessary for matching a donor liver to a recipient. HLA tissue typing is not used because it has not been known to affect outcomes. Donors are carefully screen for infectious diseases and carcinomas during the process, but blood type and body type are the essential matching criteria.

9. The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8° F. Which physician order should the nurse implement first? a. Apply forced air warming device to keep temperature > 96.8° b. Obtain basic metabolic panel every 4 hours until surgery c. Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg d. Draw arterial blood gas every 4 hours until surgery

ANS: C Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine (Neo-Synephrine) infusion to get systolic BP > 90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this scenario.

8. A family member approaches the nurse caring for their gravely ill son and states, "We want to donate our son's organs." What is the best action by the nurse? a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospital's ethics committee for a ruling. c. Notify the organ procurement organization (OPO). d. Obtain family consent to withdraw life support.

ANS: C It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary meeting with physicians and consulting the hospital's ethics committee are not appropriate actions in this scenario. Informed consent to withdraw life support is provided by the physician.

29. The nurse is preparing to administer a renal transplant recipient's first dose of mycophenolate mofetil (CellCept). Prior to administering the medication, the nurse appropriately reviews drug formulary information. What is the best understanding of this medication by the nurse? a. It is a calcineurin inhibitor used for induction therapy. b. It is an antimetabolite used for maintenance therapy. c. It is a polyclonal antibody used for maintenance therapy. d. It is an mTOR inhibitor used for maintenance therapy.

ANS: C Mycophenolate mofetil (CellCept) is an antimetabolite that inhibits T lymphocytes. CellCept is used for maintenance immunosuppression therapy.

33. The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Handoff communication from the OR included a reported output of 500 mL following anastomosis of the renal vessels and reperfusion. One hour after the transplant recipient was admitted to the PACU, the RN notes no urine output. Which physician order should the nurse implement first? a. Administer 20 mg furosemide intravenous (IV) every 4 hours as needed for urine output < 30 mL/hr. b. Administer a 500-mL bolus of 0.9% normal saline intravenously over 2 hours. c. Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline. d. Provide maintenance IV fluids of D5 NS to infuse at 100 mL/hr.

ANS: C Surgical complications following renal transplantation include ureteral obstruction. The nurse should gently irrigate the Foley catheter to determine patency. Furosemide administration should not occur until catheter obstruction has been ruled out. Administration of a fluid bolus should not occur until catheter obstruction has been ruled out. Maintenance fluids administration should be a part of the plan of care but is not the priority in this scenario.

20. The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which statement by the patient best indicates an appropriate understanding? a. "I will be gradually weaned off my medications during my lifetime." b. "After 6 months, I will be down to taking one medication for life." c. "My doctors may try to stop my steroids soon after my transplant." d. "I will only need to take my mediations every other day for life."

ANS: C Transplant programs vary in the immunosuppressant medications that are prescribed; some programs withdraw steroids after a predetermined amount of time. Transplant recipients will be on immunosuppressant medications for life taking, at minimum, two medications—a calcineurin inhibitor or mTOR inhibitor and an antimetabolite. Medications are taken at regular daily prescribed intervals to maintain therapeutic blood levels.

31. Which clinical scenario best represents hyperacute rejection? a. A cardiac transplant patient with a 3-month history of shortness of breath b. A lung transplant patient with small pustules that follow a dermatome c. A liver transplant patient with several small lumps under the skin d. An implanted renal transplant that, upon reperfusion, becomes cyanotic

ANS: D A hyperacute rejection occurs within hours or days of the transplanted organ. An implanted renal transplant that becomes cyanotic upon reperfusion represents a hyperacute rejection. A cardiac transplant patient with a 3-month history of shortness of breath represents an acute rejection. Small pustules that follow a dermatome most likely represent herpes zoster. Several small lumps under the skin may indicate squamous cell carcinoma.

30. A patient presents to the outpatient transplant clinic stating, "I would like to donate one of my kidneys." What is the best response by the nurse? a. "To be a living donor, you must be related to the recipient." b. "You must be over the age of 30 to be a living donor." c. "Living donor donation is coordinated by UNOS." d. "Let us orient you to the process required to become a donor."

ANS: D An altruistic living donor is an individual who makes a decision to donate an organ or part of an organ to a stranger. The nurse can help the patient navigate the donation process. Living donors may be related or unrelated to the potential recipient. In general, living donors are usually between the ages of 18 and 60 years. All transplant centers coordinate the living donation process.

10. The charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action? a. Renal transplant recipient, 1 day post op with a 3/10 pain level b. Lung transplant recipient, 1 day post op with a productive cough c. Heart transplant recipient, 1 day post op with a cardiac output of 4 L/min d. Liver transplant recipient, 12 hours post op with a serum glucose of 58 mg/dL

ANS: D Hypoglycemia may indicate a poorly functioning liver and requires immediate action. Postoperative pain level of 3/10 in a renal transplant patient, a lung transplant patient with a productive cough, and a heart transplant recipient with a cardiac output of 4 L/min are normal or expected findings requiring no immediate action.

14. The nurse is caring for a patient following a bilateral lung transplant. When planning postoperative care of the patient, priority is placed on pulmonary hygiene. Which statement provides the best explanation for this priority? a. Immunosuppressant medications reduce the body's ability to fight infections. b. During the early postoperative period, atelectasis decreases oxygenation. c. Pulmonary hygiene reduces the risk of early primary graft dysfunction. d. Loss of cough reflex results in decreased ability to remove secretions effectively.

ANS: D Nerves of the autonomic nervous system are severed during lung transplant surgery. This results in denervation of the lung and loss of the cough reflex. Loss of this reflex places the patient at greater risk for infection because of the potential inability to clear secretions effectively. Although immunosuppressant medications reduce the body's ability to fight infections, this is a general explanation for all increased risk of infection in transplant recipients. Atelectasis decreases oxygenation. The primary reason for pulmonary hygiene is to expectorate secretions. Primary graft dysfunction is caused by ischemia, surgical trauma, or denervation and is similar to acute respiratory distress syndrome.

17. The nurse obtains initial vital signs on a patient 2 weeks posttransplant who presents for follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action? a. Blood pressure of 100/60 mm Hg b. Serum creatinine of 1.5 mg/dL c. Hemoglobin of 9.2 gm/dL d. Tenderness over graft site

ANS: D Tenderness over the graft site may be indicative of acute rejection in a renal transplant recipient 2 weeks posttransplant. Blood pressure, serum creatinine, and hemoglobin values are all within acceptable ranges and do not require immediate action.