Free BCEN Certified Emergency Nurse (CEN) Practice Question

The correct answer is to administer albumin and initiate low-dose midodrine. This patient is presenting with signs of hepatorenal syndrome (HRS), a severe complication of advanced cirrhosis characterized by renal dysfunction, ascites, and hyponatremia.

Albumin administration helps improve effective circulating volume and renal perfusion, while midodrine, a vasoconstrictor, increases systemic vascular resistance. This combination is the recommended first-line treatment for HRS, aiming to improve renal function and overall hemodynamics.

While fluid restriction might seem logical due to hyponatremia, it's not the primary approach in this context as it doesn't address the underlying pathophysiology of HRS. Administering furosemide could worsen renal function and electrolyte imbalances in this setting. Initiating lactulose is not the priority here, as the mild confusion is likely related to hyponatremia rather than overt hepatic encephalopathy.

Transjugular intrahepatic portosystemic shunt (TIPS) placement, while sometimes used in refractory ascites, is not the initial management and carries significant risks in patients with confusion or advanced liver disease.

Emergency nurses must recognize the complex interplay of cirrhosis complications and understand the rationale behind management strategies to provide optimal care for these critically ill patients.