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 B

Explanation

A. A JP drain is not used for medication administration; its purpose is to remove fluid from the wound area.

B. The primary purpose of a JP drain is to prevent fluid from accumulating in the wound, which helps reduce the risk of infection and promotes healing by allowing continuous drainage of postoperative fluids.

C. While a JP drain helps manage fluid accumulation, it does not eliminate the need for wound irrigations if prescribed as part of the care plan.

D. A JP drain helps manage excess fluid but is not specifically designed to limit bleeding from the surgical site. Bleeding control is generally managed through other measures and monitoring.

A. Position the client in a high-Fowler's position if clear drainage is noted on the dressing. B. Assist the client into a knee-chest position to manage postoperative discomfort. C. Monitor sensory perception of the lower extremities. D. Maintain strict bed rest for the first 48 hr postoperative.

Correct Answer is C

Explanation

A. Positioning the client in a high-Fowler's position might not be appropriate immediately after a spinal fusion due to potential strain on the surgical site; the position should be adjusted based on specific postoperative orders.
B. The knee-chest position is not typically used postoperatively for a laminectomy with spinal fusion and could cause discomfort or complications.
C. Monitoring sensory perception of the lower extremities is crucial after spinal surgery to assess for potential complications such as nerve damage or compromised circulation.
D. Strict bed rest is not generally required for the entire first 48 hours; mobility and positioning should be based on the surgeon's recommendations and the client's tolerance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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