Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.

Choice A reason: While elevated bilirubin levels can indicate liver dysfunction and lead to jaundice, they are not the primary cause of hepatic coma. Bilirubin is a byproduct of red blood cell breakdown and its accumulation can cause yellowing of the skin and eyes.

Choice B reason: Calcium levels, whether high or low, can affect neuromuscular function and cardiac health, but they are not directly associated with causing hepatic coma. Hypercalcemia or hypocalcemia can present with various symptoms, but not typically with hepatic coma.

Choice C reason: Elevated ammonia levels are directly associated with hepatic coma. In patients with severe liver dysfunction, the liver cannot efficiently convert ammonia (a byproduct of protein metabolism) into urea for excretion. The accumulation of ammonia in the blood can cross the blood-brain barrier and lead to encephalopathy, resulting in confusion, altered mental status, and potentially hepatic coma.

Choice D reason: Sodium levels can affect neurological function, particularly with conditions like hypernatremia or hyponatremia. However, these imbalances are not the primary cause of hepatic coma. The direct link to hepatic coma is through elevated ammonia levels.

Choice A reason: A blood pressure of 128/76 mm Hg is within the target range for a patient with hypertension, indicating that the current therapy is effectively managing the condition. This reading is below the generally accepted threshold for hypertension, which is 140/90 mm Hg.

Choice B reason: A blood pressure of 148/78 mm Hg is above the target range for hypertension management. This reading suggests that the patient may need an adjustment in their therapy to better control their blood pressure and reduce the risk of cardiovascular complications.

Choice C reason: A blood pressure of 98/56 mm Hg is too low and may indicate hypotension, which can be a concern, especially if the patient experiences symptoms like dizziness or fainting. This reading suggests that the patient's therapy may need to be adjusted to avoid excessively lowering blood pressure.

Choice D reason: A blood pressure of 128/92 mm Hg shows an elevated diastolic pressure, which is above the target range. This indicates that the patient's hypertension is not fully controlled, and adjustments in therapy may be needed to bring both systolic and diastolic pressures within the desired range.