A nurse is caring for a client with a new tracheostomy. Which of the following actions should the nurse prioritize to prevent complications?

Choice A reason: Esophageal varices are a major complication of cirrhosis and portal hypertension. Increased portal vein pressure from liver scarring causes collateral vessel formation, including varices in the esophagus. These fragile vessels can rupture, leading to life-threatening gastrointestinal bleeding, requiring urgent monitoring and interventions like band ligation or beta-blockers to reduce risk.

Choice B reason: Pulmonary edema is not directly associated with cirrhosis or portal hypertension. It occurs in heart failure or fluid overload, which may be secondary to other conditions but not a primary complication of liver disease. Cirrhosis complications focus on portal system effects, like varices, rather than pulmonary fluid accumulation.

Choice C reason: Hypoglycemia may occur in end-stage cirrhosis due to impaired gluconeogenesis in the liver, but it is not the primary complication of portal hypertension. Esophageal varices pose a more immediate, life-threatening risk due to potential massive bleeding, making them a higher monitoring priority than metabolic disturbances like hypoglycemia.

Choice D reason: Hypernatremia is not a common complication of cirrhosis or portal hypertension. Cirrhosis may lead to hyponatremia due to impaired water excretion and fluid retention from low albumin and aldosterone dysregulation. Monitoring for varices is more critical, as they pose a direct risk of catastrophic bleeding compared to electrolyte imbalances.

Choice A reason: Blood pressure of 104/72 mm Hg, pulse of 80, and respiratory rate of 16 are within normal ranges for a postoperative patient. These vital signs indicate stable hemodynamic status and adequate oxygenation. Opioids may slightly lower blood pressure or respiratory rate, but these values do not suggest distress or complications requiring immediate provider notification. The patient’s condition appears stable, with no critical abnormalities warranting urgent intervention.

Choice B reason: Blood pressure of 110/60 mm Hg, pulse of 70, and respiratory rate of 14 are normal for a postoperative patient. These parameters reflect stable cardiovascular and respiratory function. Opioids can cause mild respiratory depression, but a rate of 14 is acceptable. No signs of opioid overdose, hypotension, or tachycardia are present, indicating no need for immediate provider contact or intervention.

Choice C reason: Blood pressure of 90/50 mm Hg, pulse of 120, and respiratory rate of 18 indicate potential opioid-related complications or postoperative issues like hypovolemia or shock. Hypotension and tachycardia suggest inadequate perfusion, possibly due to bleeding or opioid-induced vasodilation. These signs require immediate provider notification to assess for overdose, hemorrhage, or other serious conditions affecting systemic circulation and tissue oxygenation.

Choice D reason: Blood pressure of 120/80 mm Hg, pulse of 100, and respiratory rate of 20 are within acceptable ranges, though the pulse is slightly elevated. This could reflect pain or mild stress but does not indicate critical instability. Opioids may cause mild tachycardia, but these vital signs do not necessitate immediate provider contact as they suggest stable physiological function without severe complications.