A client with liver failure is at risk for bleeding due to impaired synthesis of clotting factors.
Which assessment should the nurse prioritize?

Assessing the patient's urine output.

Assessing the patient's oxygen saturation.

Assessing the patient's blood pressure.

Assessing the patient's INR (International Normalized Ratio) and PT (Prothrombin Time) levels.

Answer and Explanation

The Correct Answer is D

Evaluating a patient with liver failure involves understanding the biosynthetic pathways of coagulation. The liver produces vitamin K dependent clotting factors, and monitoring laboratory trends is essential to assess the severity of coagulopathy and the risk for spontaneous internal bleeding.

Choice A rationale

Urine output monitoring assesses renal perfusion and fluid balance, which is important in liver failure due to the risk of hepatorenal syndrome. However, it does not directly measure the liver ability to synthesize the essential factors needed for clotting.

Choice B rationale

Oxygen saturation measures the percentage of hemoglobin bound to oxygen in the blood. While respiratory status is important, it is not the priority assessment for a patient specifically at risk for hemorrhage due to impaired clotting factor synthesis.

Choice C rationale

Blood pressure can indicate hemodynamic stability and signs of shock if a bleed has already occurred. However, it is a late indicator of hemorrhage and does not provide information regarding the actual physiological capacity for blood coagulation.

Choice D rationale

The liver synthesizes factors I, II, VII, IX, and X. PT and INR directly measure the extrinsic pathway of coagulation. A normal PT is 11 to 13.5 seconds, and a normal INR is 0.8 to 1.1.

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Correct Answer is C

Explanation

Management of hypertensive crisis involves using calcium channel blockers to achieve rapid vascular relaxation. Knowledge of pharmacodynamics is necessary to explain how nicardipine reduces systemic vascular resistance to mitigate the risk of cerebrovascular accidents and end organ damage in emergencies.

Choice A rationale

Nicardipine is a dihydropyridine calcium channel blocker that primarily causes vasodilation. It does not act as a positive chronotrope. Increasing heart rate in a hypertensive crisis could dangerously increase myocardial oxygen demand and exacerbate the clinical situation.

Choice B rationale

The medication does not possess analgesic properties or stimulate endorphin release. While the headache may improve as intracranial pressure decreases from lowered blood pressure, the primary pharmacological mechanism is vascular smooth muscle relaxation rather than pain modulation.

Choice C rationale

Nicardipine inhibits calcium ion influx into vascular smooth muscle, leading to rapid peripheral vasodilation. In a hypertensive emergency (BP > 180/120 mm Hg), quick reduction is critical to prevent intracranial hemorrhage, encephalopathy, or ischemic stroke.

Choice D rationale

Nicardipine does not function as a diuretic. While lowering blood pressure reduces renal strain, it does not promote fluid loss through the kidneys. Diuretics like furosemide are separate agents used for volume related hypertension or edema.

A. Respirations 18 per minute and pulse 60 bpm. B. Pulse 106 bpm and temperature 98.4°F. C. Blood pressure 92/60 mm Hg and pulse 100 bpm. D. Pulse 130 bpm and urine output 25 mL/hr.

Correct Answer is D

Explanation

This scenario requires applying knowledge of burn pathophysiology, specifically the emergent phase and fluid resuscitation. Understanding clinical indicators of hypovolemia, such as heart rate and urine output, is essential to recognize inadequate perfusion and potential hypovolemic shock.

Choice A rationale

Normal adult respirations range from 12 to 20 breaths per minute. A pulse of 60 bpm is at the low end of the normal range of 60 to 100 bpm, which does not suggest hypovolemic shock.

Choice B rationale

A temperature of 98.4 F is within the normal range of 97 F to 99 F. While a pulse of 106 bpm is slightly tachycardic, it is not a definitive indicator of critical fluid deficit.

Choice C rationale

A blood pressure of 92/60 mm Hg is borderline low, but a pulse of 100 bpm is at the upper limit of normal. These findings are less concerning than those indicating direct organ hypoperfusion.

Choice D rationale

Tachycardia of 130 bpm and urine output below 30 mL/hr signify inadequate fluid resuscitation. Normal urine output is at least 0.5 mL/kg/hr, or 30 mL/hr, indicating decreased renal perfusion and significant hypovolemia in burn patients.

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A client with liver failure is at risk for bleeding due to impaired synthesis of clotting factors. Which assessment should the nurse prioritize?

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Explanation

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A client with liver failure is at risk for bleeding due to impaired synthesis of clotting factors.
Which assessment should the nurse prioritize?