hard · NCLEX-RN Management of Care

The nurse is formulating the immediate care plan for this patient to support potential organ procurement. Which interventions should the nurse include? Select all that apply. Apply the response specifically to this case: neurologic determination of death and organ-procurement referral with treatment-team independence, required donor-network notification, family questions, and continued physiologic support.

  1. Administer prescribed intravenous potassium chloride to correct hypokalemia.
  2. Apply active warming blankets to maintain core temperature above 36°C (96.8°F).
  3. Titrate norepinephrine infusion as prescribed to achieve a target MAP of 65 mmHg or higher.
  4. Switch the intravenous fluid from normal saline to 5% dextrose in water if serum sodium rises above 155 mEq/L.
  5. Initiate a continuous intravenous heparin infusion to prevent microthrombi in donor organs.
  6. Discontinue mechanical ventilation for 10 minutes hourly to assess for spontaneous respiratory efforts.

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