Gastrointestinal Question #4

Question

The nurse is caring for a client with a history of alcoholism and ascites. Assessment findings reveal a capillary refill of > 6 seconds, tachycardia, dyspnea, and blood pressure of 82/48. The nurse recognizes the onset of hepatopulmonary syndrome and expects to find which assessment data?

Answers

  1. Pulse oximetry at 82%
    • Rationale:
  2. Respiratory rate < 10 breaths/minute
    • Rationale:
  3. Flat jugular veins.
    • Rationale:
  4. Cloudy paracentesis fluid.
    • Rationale:

Overview

Explanation

Low oxygen saturation indicates pulmonary complications that may occur with increased intrapulmonary vascular dilations with low blood oxygenation. Dyspnea and crackles may be observed and pulse oximetry readings will reflect hypoxemia Respiratory rate will usually be elevated, not low and jugular veins may be distended (B and C are incorrect selections). The question does not refer to a paracentesis procedure; therefore, so option D would be incorrect.

Learning Outcomes

Test Taking Tip

Video Rationale