A client with liver cirrhosis presents with confusion, lethargy, and asterixis. Which complication is the client most likely experiencing?

Hepatic encephalopathy

Ascites

Portal hypertension

Jaundice

Answer and Explanation

The Correct Answer is A

Liver cirrhosis leads to progressive liver dysfunction, reducing the organ’s ability to detoxify harmful substances such as ammonia. When toxins accumulate in the bloodstream and cross the blood-brain barrier, they affect central nervous system function. This results in neuropsychiatric changes ranging from mild confusion to coma. Clinical signs such as asterixis, altered mental status, and lethargy are hallmark features of this complication.

Rationale:
A. Hepatic encephalopathy is the correct complication because it results from the accumulation of neurotoxic substances, particularly ammonia, due to impaired liver detoxification in cirrhosis. The client’s confusion, lethargy, and asterixis (flapping tremor) are classic neurological manifestations. These findings indicate altered cerebral function secondary to hepatic failure.

B. Ascites refers to the accumulation of fluid in the peritoneal cavity due to portal hypertension and hypoalbuminemia. While it is a common complication of cirrhosis, it primarily presents as abdominal distension and weight gain rather than neurological changes. It does not explain confusion or asterixis.

C. Portal hypertension is increased pressure within the portal venous system caused by resistance to blood flow through the diseased liver. Although it leads to complications such as variceal bleeding and ascites, it is a vascular condition and does not directly cause neurological symptoms like confusion or asterixis.

D. Jaundice results from the accumulation of bilirubin due to impaired hepatic metabolism and excretion. It is characterized by yellowing of the skin and sclera but does not typically cause acute changes in mental status or neuromuscular findings such as asterixis.

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Correct Answer is C

Explanation

Assist-control (A/C) mechanical ventilation is a mode used to support clients who require full or partial respiratory assistance. In this mode, the ventilator delivers a preset tidal volume or pressure for every breath, whether it is triggered by the client or initiated by the machine. The set respiratory rate ensures a minimum number of breaths, while any additional spontaneous breaths initiated by the client are also fully supported. This mode ensures adequate ventilation while allowing the client some control over breathing frequency.

Rationale:
A. The client has achieved full control of their ventilation and can stop using the ventilator is incorrect because assist-control ventilation is still providing full respiratory support. The presence of spontaneous breaths does not indicate readiness for weaning or discontinuation. The ventilator remains essential in ensuring adequate oxygenation and ventilation.

B. The ventilator will not provide any assistance if the client's breathing is above the set rate is incorrect because in assist-control mode, every spontaneous breath triggered by the client is fully supported. Each breath receives the preset tidal volume or pressure, regardless of whether it exceeds the baseline respiratory rate. This ensures consistent ventilatory support even with increased patient effort.

C. The ventilator will assist every breath initiated by the client at whatever rate they choose is correct because assist-control ventilation delivers a full mechanical breath with each patient-triggered effort. The machine ensures both minimum ventilation and full support of spontaneous breaths. This allows the client to increase their respiratory rate without losing ventilatory assistance.

D. The ventilator will adjust the set rate to match the client's spontaneous breathing rate is incorrect because assist-control ventilation does not self-adjust based on patient effort. The preset rate remains constant, and spontaneous breaths are added on top of it. Any adjustments to settings must be made manually by the healthcare provider based on clinical assessment.

A. Wait 1 minute before suctioning again if repeated suctioning is necessary. B. Insert the catheter slowly to prevent trauma to the trachea. C. Dispose of the suction catheter after each use. D. Suction at set intervals based on a schedule. E. Perform hyperoxygenation before suctioning.

Correct Answer is ["A","B","C","E"]

Explanation

Tracheostomy suctioning is performed to maintain airway patency by removing secretions from the tracheobronchial tree. It is an invasive procedure that can temporarily reduce oxygenation, irritate airway mucosa, and trigger vagal stimulation leading to complications such as hypoxia, bradycardia, and mucosal injury. Safe suctioning requires proper technique, sterile equipment, and careful monitoring of the client’s respiratory status before, during, and after the procedure.

Rationale:
A. Waiting 1 minute before suctioning again allows the client time to reoxygenate and recover from potential hypoxia caused by suctioning. Repeated suctioning without adequate rest can lead to oxygen desaturation, bronchospasm, and cardiac stress. This pause helps stabilize oxygen levels and reduces procedural complications.

B. Inserting the catheter slowly is important to minimize trauma to the tracheal mucosa. Rapid insertion can cause irritation, bleeding, and stimulation of the vagus nerve, which may result in bradycardia or coughing. Gentle insertion ensures safer navigation of the airway and reduces patient discomfort.

C. Disposing of the suction catheter after each use is a key infection control practice when using sterile suction technique for tracheostomy care. Reusing a catheter increases the risk of introducing pathogens into the lower respiratory tract. Proper disposal prevents cross-contamination and reduces the risk of ventilator-associated or tracheostomy-related infections.

D. Suctioning at set intervals based on a schedule is not recommended because suctioning should be performed based on clinical need rather than routine timing. Unnecessary suctioning can damage airway mucosa and cause hypoxia. Indications include audible secretions, visible mucus, or signs of respiratory distress.

E. Performing hyperoxygenation before suctioning is essential to prevent hypoxemia during the procedure. Increasing oxygen delivery prior to suctioning helps offset the temporary loss of oxygen during catheter insertion and secretion removal. This practice reduces the risk of oxygen desaturation and cardiac complications.

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A client with liver cirrhosis presents with confusion, lethargy, and asterixis. Which complication is the client most likely experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving assist control mechanical ventilation has a respiratory rate set to 14 breaths per minute. The nurse observes that the client is initiating breaths that are above the preset rate. What is the most appropriate interpretation of this situation?

Correct Answer is C

Explanation

Which of the following actions should a nurse perform when suctioning clients with tracheostomy tubes, according to best practices? Select All that Apply.

Correct Answer is ["A","B","C","E"]

Explanation

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