1.  Before initiating a BD/DNC examination, the cause of coma must be known and capable of causing irreversible brain injury.

A. True
B. False

2.  Which of the following must be corrected before proceeding with BD/DNC testing?

A. Hypothermia (core temperature below guideline threshold)
B. Significant hypotension
C. Sedative medications that may confound the examination
D. Severe metabolic abnormalities
E. All of the above

3.  Which finding is NOT consistent with brain death?

A. No pupillary response
B. No corneal reflex
C. Flexor withdrawal of the leg to painful stimulation
D. No cough reflex

4.  The presence of spinal reflexes automatically excludes the diagnosis of brain death.

A. True
B. False

5.  Which cranial nerve reflexes are typically assessed during the neurologic examination?

A. Pupillary
B. Corneal
C. Oculocephalic (when appropriate)
D. Oculovestibular
E. Gag and cough
F. All of the above

6.  Prior to apnea testing, which condition is required?

A. Patient should be normotensive
B. Adequately oxygenated
C. Euvolemic when possible
D. Normothermic
E. All of the above

7.  If the patient develops severe hypoxemia or hemodynamic instability during apnea testing, the test should be terminated.

A. True
B. False

8.  Apnea testing demonstrates brain death when:

A. The patient breathes once during testing
B. The patient has no respiratory effort despite an adequate rise in PaCO₂ meeting guideline thresholds
C. Oxygen saturation remains above 95%
D. Heart rate decreases

9.  Ancillary testing should be obtained when:

A. The clinical examination cannot be fully completed
B. Apnea testing cannot be safely completed
C. Confounding factors cannot be eliminated
D. Any of the above

10.  Ancillary testing should routinely replace the neurologic examination.

A. True
B. False

11.  Who is responsible for determining that all prerequisites for BD/DNC testing have been met?

A. Bedside nurse
B. Respiratory therapist
C. Physician performing the determination (or qualified practitioner per institutional policy)
D. Organ procurement organization

12.  Which statement regarding the Organ Procurement Organization (OPO) is correct?

A. The OPO determines brain death.
B. The treating physician determines brain death independently; the OPO is notified according to policy after referral criteria are met.
C. The OPO performs the neurologic examination.
D. Brain death cannot be declared until OPO approval.

13.  Documentation of BD/DNC should include completion of prerequisites, neurologic examination findings, apnea testing (or ancillary testing when indicated), and the official time of death.

A. True
B. False

14.  A patient with devastating intracranial hemorrhage has absent brainstem reflexes. The patient received a large dose of pentobarbital several hours earlier. What is the most appropriate next step?

A. Proceed immediately with apnea testing.
B. Declare brain death.
C. Delay testing until drug effect has been excluded or use an appropriate ancillary approach when indicated.
D. Notify the OPO first.

15.  During apnea testing, the patient's blood pressure falls significantly and oxygen saturation rapidly declines before the target PaCO₂ threshold is reached. What is the best next step?

A. Continue until PaCO₂ reaches the target.
B. Terminate apnea testing, stabilize the patient, and consider ancillary testing if appropriate.
C. Declare brain death.
D. Restart the apnea test immediately.

16.  Which of the following hemodynamic parameters is considered a clinical trigger for referring to a potential organ donor?

A. Sustained cerebral perfusion pressure (CPP) greater than 100 mmHg.
B. Sustained intracranial pressure (ICP) less than 15 mmHg.
C. Sustained cerebral perfusion pressure (CPP) between 70 and 80 mmHg.
D. Sustained cerebral perfusion pressure (CPP) less than 60 mmHg, refractory to treatment.

17.  What are the minimum blood pressure prerequisites required before initiating a clinical brain death evaluation?

A. Systolic blood pressure ≥ 90 mm Hg and MAP ≥ 65
B. Systolic blood pressure ≥ 100 mm Hg and MAP ≥ 75
C. Systolic blood pressure ≥ 110 mm Hg and MAP ≥ 80
D. Mean arterial pressure (MAP) ≥ 60, regardless of systolic pressure

18.  To meet the temperature prerequisite for a brain death examination, a patient must maintain normothermia or mild hypothermia at what core temperature and for what duration?

A. ≥ 36.5° C (97.7° F) for > 12 hours
B. ≥ 35° C (95.0° F) for > 24 hours
C. ≥ 36° C (96.8° F) for > 24 hours
D. ≥ 37° C (98.6° F) for > 48 hours

19.  While assessing the absence of brainstem reflexes, how long should a physician wait after irrigating an ear with cold water before testing the opposite side?

A. Allow 1 minute after injection; wait at least 5 minutes between sides
B. Allow 2 minutes after injection; wait at least 10 minutes between sides
C. Allow 30 seconds after injection; wait at least 2 minutes between sides
D. No waiting period is required between sides as long as the first side is negative

20.  Which of the following physical examination findings would immediately exclude a clinical diagnosis of brain death?

A. Triple flexion response in the lower extremities
B. Babinski sign upon plantar stimulation
C. Grimacing to deep pressure on the supraorbital ridge
D. Spontaneous shoulder elevation without significant tidal volume

21.  What is the required target parameter for preoxygenation before commencing the apnea test?

A. 100% FiO2 for at least 5 minutes to achieve PaO2 > 100 mm Hg
B. 100% FiO2 for at least 10 minutes to ideally achieve PaO2 > 200 mm Hg.
C. 50% FiO2 for at least 20 minutes to achieve PaO2 > 150 mm Hg
D. Hyperventilation to achieve a baseline PaCO2 < 30 mm Hg

22.  During an apnea test, an arterial blood gas is drawn at 8–10 minutes. Which combination of results confirms a positive apnea test supporting brain death?

A. pH < 7.35 and PaCO₂ ≥ 50 mm Hg
B. pH < 7.30, PaCO₂ ≥ 60 mm Hg, or a 20 mm Hg increase over baseline normal PaCO₂.
C. pH < 7.40 and PaCO₂ ≥ 45 mm Hg
D. Any pH level, provided the PaCO₂ has doubled from baseline

23.  A physician is conducting an apnea test, and at minute 4, the patient's systolic blood pressure drops to 95 mm Hg and the pulse oximeter reads 83%. What is the correct immediate action?

A. Continue the test for the full 8 minutes to ensure accurate CO2 accumulation
B. Reconnect the ventilator, immediately draw an arterial blood sample, and analyze the ABG
C. Turn the oxygen flow up to 15 L/min via the nasal cannula and continue observing
D. Immediately order a confirmatory nuclear isotope angiography and abandon the ABG

24.  Which of the following clinical scenarios is considered a "pitfall" that interferes with the clinical diagnosis of brain death, necessitating an ancillary test?

A. Present deep tendon reflexes
B. Spontaneous sweating and tachycardia
C. Severe facial trauma or preexisting pupillary abnormalities
D. Absence of diabetes insipidus

25.  As soon as it is anticipated that a patient will meet the criteria for Imminent Death, what is the required timeframe for Timely Notification to the Organ Procurement Organization (OPO)?

A. Within 30 minutes of meeting criteria.
B. Within 1 hour
C. Within 6 hours of meeting criteria.
D. Within 24 hours meeting criteria.

26.  According to the Kettering Health policy, at what point is organ donation typically discussed with the patient's family?

A. As soon as a poor prognosis per the physician is identified.
B. Only after the patient has been pronounced brain dead.
C. Prior to the determination of donor suitability.
D. When the patient's GCS score falls below 5.