A student nurse is completing an internship in the emergency department. The student asks the preceptor. "How is emergency department nursing different from other areas of nursing practice? How should the experienced emergency department nurse respond? Select all that apply.

Rationale:

A. In advanced cirrhosis, the liver’s synthetic function is impaired, leading to decreased production of albumin. Low albumin contributes to ascites, peripheral edema, and decreased oncotic pressure. A value of 7.2 g/dL is well above the normal range and is inconsistent with cirrhosis, making this an unlikely finding in this disease process.

B. Thrombocytopenia is a common finding in cirrhosis due to multiple mechanisms. Portal hypertension causes splenic enlargement (splenomegaly) and sequestration of platelets, while impaired liver function decreases thrombopoietin production, reducing platelet formation. A platelet count of 75,000 cells/mm³ reflects significant reduction and is consistent with advanced liver disease.

C. Amylase is an enzyme produced primarily by the pancreas and salivary glands. While levels may be slightly elevated in pancreatic disorders, it is not a specific or consistent marker of liver dysfunction. A value of 200 units/L is within or near the normal range and does not correlate with cirrhosis.

D. Elevated ammonia occurs in cirrhosis because the damaged liver cannot efficiently convert ammonia to urea, leading to accumulation in the blood. High ammonia levels are associated with hepatic encephalopathy, causing confusion, altered mental status, and other neurologic symptoms. A value of 96 mcg/dL is above the normal range and consistent with advanced liver disease.

E. The liver synthesizes most clotting factors, so impaired hepatic function in cirrhosis leads to coagulopathy, reflected as a prolonged prothrombin time (PT). A PT of 22 seconds indicates significant impairment of the clotting cascade, which is a common complication of advanced cirrhosis.

Rationale:

A. Neurological status is important to assess, as hypoxemia can lead to confusion or altered mental status. However, this is a secondary assessment after identifying and addressing the primary cause of hypoxemia. It is not the first action.

B. Lung sounds should be assessed first because the client is experiencing shortness of breath with a low oxygen saturation (88%, below the normal 95–100%). In acute pancreatitis, respiratory complications such as pleural effusion or acute respiratory distress syndrome (ARDS) can develop. Assessing lung sounds immediately helps determine the cause of hypoxemia, guides oxygen therapy, and identifies the need for urgent interventions like supplemental oxygen or respiratory support.

C. Abdominal girth and tenderness are relevant for monitoring pancreatitis progression and ascites, but these assessments do not directly address the acute respiratory compromise. They are not the first priority in a client with hypoxemia.

D. Vital signs for hypotension and tachycardia are important because circulatory instability can worsen oxygen delivery. While vital signs should be checked promptly, auscultating lung sounds provides more specific information about respiratory compromise, which is the immediate priority in a client with low oxygen saturation.