A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the client's intake of protein.

Restrict the client's intake of fluids.

Administer vitamin K

Administer diuretics.

Answer and Explanation

The Correct Answer is A

A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.

B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.

C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.

D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.

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Correct Answer is D

Explanation

A. Metabolic alkalosis is characterized by an elevated pH and elevated bicarbonate, which is not consistent with these ABG values.
B. Respiratory alkalosis presents with an elevated pH and decreased PaCO2, opposite of the client's findings.
C. Metabolic acidosis would show a decreased pH with a low bicarbonate level, but this client's bicarbonate is within normal range.
D. Respiratory acidosis is indicated by a low pH and elevated PaCO2 due to hypoventilation, which aligns with the client's ABG values and respiratory rate.

A. Handrails are present in the bathroom. B. Uses a microwave for cooking. C. Scatter rugs are present in the kitchen. D. Electrical cords are placed along the walls.

Correct Answer is C

Explanation

A. Handrails in the bathroom are a safety feature designed to prevent falls, which is beneficial for clients with decreased vision and other mobility issues.

B. Using a microwave for cooking is generally safe and convenient, especially for clients with decreased vision, as it reduces the need for handling hot pots and pans.

C. Scatter rugs can be a significant safety risk as they may cause tripping hazards, particularly for individuals with vision problems who may not see them clearly.

D. Electrical cords placed along the walls are less of a risk compared to scatter rugs. While they should be properly managed to avoid tripping hazards, they do not pose as immediate a risk as scattered rugs.

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A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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