hard · NCLEX-RN Management of Care
A mechanically ventilated client has a severe traumatic brain injury. The hospital's jointly approved OPO referral policy requires prompt notification for absent brainstem reflexes, planned discussion of withdrawal of life-sustaining treatment, or a GCS score of 5 or less. Which situations require the RN to notify the OPO? Select all that apply.
- The client has a documented loss of corneal and pupillary reflexes.
- The primary healthcare provider and family are planning to discuss withdrawal of life-sustaining treatment.
- The nurse plans to perform a clinical assessment for neurologic determination of death while the client's core temperature is 34.5°C (94.1°F).
- The client's Glasgow Coma Scale (GCS) score decreases to 4.
- The family asks about the client's prognosis, prompting the nurse to initiate a discussion about organ donation options.
Sign up free to see the explanation and track your rank →
More NCLEX-RN Management of Care practice
- Which action should the nurse take first?
- A client with a new tracheostomy requires suctioning. Which part of this care can be deleg
- Which instruction is essential to ensure safety and accuracy?
- Which response by the RN best demonstrates professional advocacy?
- Which action can be delegated to the LPN/VN?
- The RN is prioritizing four clients for morning care. Which client should be seen first?
- Which finding would most likely indicate that the medication is having the intended therap
- Which task is most appropriate to retain and perform solely by the RN?