A nurse is planning care for a client who has cirrhosis of the liver.
Which of the following actions should the nurse include in the plan? (Select all that apply.)

The client has respiratory acidosis as indicated by a pH of 7.25 (normal: 7.35-7.45) and elevated pCO2 of 62 mm Hg (normal: 35-45 mm Hg). This condition occurs when the lungs cannot remove enough CO2, leading to its buildup and lowering the blood pH. Immediate interventions like intubation can help manage airway and ventilation. Starting an IV drip of 0.9% sodium chloride can help address dehydration, supporting hemodynamic stability. Monitoring the correct placement of the endotracheal tube ensures effective ventilation. Regular arterial blood gases assessment helps evaluate the effectiveness of interventions and the client's respiratory status.

Prepare the client for intubation: Intubation is essential to secure the airway and provide mechanical ventilation, addressing hypoxia and hypercapnia by improving gas exchange.

Start a 0.9% sodium chloride IV drip: This fluid helps in correcting dehydration, supporting blood pressure, and improving renal perfusion, which is critical in managing acid-base balance.

Correct placement of endotracheal tube: Ensuring the tube is in the correct position guarantees effective ventilation and prevents complications such as aspiration or pneumothorax.

Arterial blood gases: Regular ABG assessments help monitor the effectiveness of ventilation and guide adjustments in therapy, ensuring the client’s acid-base balance is maintained.

Metabolic acidosis is not correct as the primary issue here is a respiratory one, indicated by elevated pCO2 and lower pH.

Respiratory alkalosis is incorrect as it would present with a high pH and low pCO2, unlike the client's findings.

Metabolic alkalosis is ruled out because it would show elevated pH and bicarbonate levels, which is not seen in the client's ABG results.

Choice A rationale

Decreased serum lipase is not expected in acute pancreatitis; rather, lipase levels are typically elevated due to pancreatic enzyme leakage into the bloodstream.

Choice B rationale

Increased serum calcium is not a typical finding in acute pancreatitis; instead, hypocalcemia can occur due to fat necrosis and soap formation.

Choice C rationale

Decreased WBC is not expected; an elevated WBC count is common due to the inflammatory response associated with pancreatitis.

Choice D rationale

Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.