Medical Surgical Liver Cirrhosis #1

Question

The nurse provides 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 mm Hg. The nurse recognizes the onset of hepatopulmonary syndrome and expects to find which assessment data?

Answers

  1. Flat jugular veins.
    • Rationale:

      The nurse anticipates that the client will experience jugular vein distension with this syndrome; therefore, a flat jugular vein is not expected. Hepatopulmonary syndrome is caused by blood vessels in the lungs dilating and increasing in number, making it hard for red blood cells (RBCs) to properly absorb oxygen. Dyspnea and crackles may be observed and pulse oximetry readings will reflect hypoxemia (e.g., pulse oximetry at 82%).

  2. Pulse oximetry at 82%
    • Rationale:

      Because this syndrome impacts the ability of RBCs to absorb oxygen, the nurse anticipates hypoxemia which is evidenced by a pulse oximetry reading of 82%. Hepatopulmonary syndrome is caused by blood vessels in the lungs dilating and increasing in number, making it hard for red blood cells (RBCs) to properly absorb oxygen. Dyspnea and crackles may be observed and pulse oximetry readings will reflect hypoxemia (e.g., pulse oximetry at 82%).

  3. Cloudy paracentesis fluid.
    • Rationale:

      The question does not refer to a paracentesis procedure; therefore, this data is not expected. Hepatopulmonary syndrome is caused by blood vessels in the lungs dilating and increasing in number, making it hard for red blood cells (RBCs) to properly absorb oxygen. Dyspnea and crackles may be observed and pulse oximetry readings will reflect hypoxemia (e.g., pulse oximetry at 82%).

  4. Respiratory rate less than 10 breaths/minute.
    • Rationale:

      The respiratory rate for a client who experiences hepatopulmonary syndrome will experience tachypnea (i.e., elevated respirations) not bradypnea (i.e., decreased respirations). Hepatopulmonary syndrome is caused by blood vessels in the lungs dilating and increasing in number, making it hard for red blood cells (RBCs) to properly absorb oxygen. Dyspnea and crackles may be observed and pulse oximetry readings will reflect hypoxemia (e.g., pulse oximetry at 82%).

Overview

Hepatopulmonary syndrome is caused by blood vessels in the lungs dilating and increasing in number, making it hard for red blood cells (RBCs) to properly absorb oxygen.

Explanation

Learning Outcomes

Hepatopulmonary syndrome leaves the lungs unable to deliver adequate amounts of oxygen to the body, which leads to hypoxemia (i.e., low oxygen levels). Low oxygen saturation indicates pulmonary complications that may occur with increased intrapulmonary vascular dilatations with low blood oxygenation. Dyspnea and crackles may be observed and pulse oximetry readings will reflect hypoxemia (e.g., pulse oximetry at 82%).

Test Taking Tip

Consider the pathophysiology of hepatopulmonary syndrome to answer this question correctly.

Video Rationale