Difficulty: Medium
Average Score: 80%
Simulated
The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained?
Correct answer
A
Rationale
Urine output at 100mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a \mathrm{pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the 'rule of 100s ' in which the systolic blood pressure is maintained at 100mmHg , urine output at 100mL per hour, heart rate at 100 beats per minute, and \mathrm{PaO}_2 at 100mmHg .