The nurse is securing a tracheostomy tube for a client post-procedure. Which action should the nurse take to ensure proper tracheostomy care?

Choice A reason: Lactulose increases stool frequency and liquidity to excrete ammonia in hepatic encephalopathy. A reduction in liquid stools would indicate reduced effectiveness, as the medication’s cathartic effect is essential for ammonia removal. This is not the expected therapeutic response, as increased bowel movements are desired.

Choice B reason: Lactulose reduces blood ammonia levels in hepatic encephalopathy by promoting its excretion in stool, improving mental status. Ammonia accumulation causes neurological symptoms like confusion. Improved cognition and alertness are the primary therapeutic goals, making this the expected response to effective lactulose therapy.

Choice C reason: Ambulation ability is unrelated to lactulose’s mechanism in hepatic encephalopathy. While improved mental status may indirectly aid mobility, lactulose directly targets ammonia reduction, not physical function. This is not the primary therapeutic response, as the medication addresses neurological, not musculoskeletal, symptoms in this condition.

Choice D reason: Lactulose does not directly affect urine output, as it acts in the gastrointestinal tract to excrete ammonia. While hydration status may influence urine, the medication’s primary effect is on bowel movements and ammonia reduction, not renal function, making this an incorrect therapeutic expectation.

Choice A reason: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.

Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.

Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.

Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.