A nurse is caring for a client with cirrhosis and portal hypertension. Which of the following complications should the nurse monitor for?
Esophageal varices
Pulmonary edema
Hypoglycemia
Hypernatremia
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elevated troponin is a strong indicator of myocardial infarction, reflecting massive cardiac cell destruction. Troponins are proteins released from damaged cardiomyocytes during ischemia. Their high specificity for cardiac muscle makes them a key biomarker for diagnosing acute myocardial infarction, as levels rise within hours of cell death.
Choice B reason: Decreased hemoglobin indicates anemia or blood loss but is not specific to massive cell destruction in myocardial infarction. It may occur secondary to chronic conditions or bleeding but does not directly reflect acute cardiac tissue damage, unlike troponin, which is a precise marker of cardiomyocyte necrosis.
Choice C reason: Elevated creatinine reflects renal dysfunction, not massive cell destruction in myocardial infarction. It indicates impaired kidney filtration, often due to hypoperfusion or chronic disease. While shock from infarction may cause secondary renal injury, creatinine is not a direct marker of cardiac cell death, unlike troponin.
Choice D reason: Decreased sodium (hyponatremia) may occur in heart failure or fluid overload but is not a marker of massive cell destruction. It reflects electrolyte imbalance, not tissue necrosis. In myocardial infarction, sodium levels are typically unaffected unless complicated by other conditions, making it irrelevant to acute cardiac damage.
Correct Answer is B
Explanation
Choice A reason: A decrease in blood pressure is not an indicator of adequate fluid replacement in burn patients. Severe burns cause hypovolemia from fluid loss, leading to hypotension. Adequate resuscitation should increase blood pressure by restoring intravascular volume, improving cardiac output, and ensuring tissue perfusion, not decrease it.
Choice B reason: A decrease in heart rate indicates adequate fluid replacement in burn patients. Severe burns cause hypovolemia, triggering tachycardia as the heart compensates for low blood volume. Restoring intravascular volume with IV fluids reduces the sympathetic drive, slowing the heart rate to normal, reflecting improved perfusion and hemodynamic stability.
Choice C reason: A decrease in urine output is not a sign of adequate fluid replacement. Burn patients require high urine output (0.5-1 mL/kg/hr) to ensure renal perfusion and prevent acute kidney injury. Adequate resuscitation increases urine output by restoring blood volume, not decreasing it, as low output indicates ongoing hypovolemia.
Choice D reason: A decrease in weight is not expected with adequate fluid replacement. Burn patients receive large volumes of IV fluids to counter hypovolemia and third-spacing, often leading to weight gain from fluid retention. A weight decrease could indicate inadequate resuscitation or diuresis, not successful restoration of intravascular volume.
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