Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?

Choice A reason: The arterial blood gas values pH 7.25, HCO3- 19 mEq/L, and PaCO2 30 mm Hg are indicative of metabolic acidosis, which is commonly seen in chronic kidney disease (CKD). In CKD, the kidneys lose their ability to excrete hydrogen ions and retain bicarbonate, leading to a decrease in blood pH (acidosis) and a reduction in bicarbonate (HCO3-). The PaCO2 value is slightly lower as a compensatory mechanism by the lungs to help balance the pH.

Choice B reason: The values pH 7.30, HCO3- 26 mEq/L, and PaCO2 50 mm Hg suggest a state of respiratory acidosis with partial metabolic compensation. This is not typically expected in chronic kidney disease. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide (CO2) in the blood. The bicarbonate (HCO3-) level is within the normal range, indicating that it is not the primary disorder in this context.

Choice C reason: The values pH 7.50, HCO3- 20 mEq/L, and PaCO2 32 mm Hg are consistent with respiratory alkalosis, where the pH is elevated due to hyperventilation leading to a loss of CO2. This condition is not typically associated with chronic kidney disease. The bicarbonate level is slightly below normal but not enough to indicate a significant metabolic disorder.

Choice D reason: The values pH 7.55, HCO3- 30 mEq/L, and PaCO2 31 mm Hg indicate metabolic alkalosis, which is characterized by an elevated pH and increased bicarbonate. This condition can occur due to excessive loss of acids (e.g., vomiting) or an increase in bicarbonate but is not typically expected in chronic kidney disease.

Choice A reason: Explaining that diarrhea is expected and that it is how the body gets rid of ammonia is accurate. Lactulose is often prescribed for patients with hepatic encephalopathy, and its purpose is to reduce blood ammonia levels by promoting bowel movements. Diarrhea is a common and anticipated side effect, as it helps eliminate ammonia from the body.

Choice B reason: Recommending Kaopectate for loose stools is not appropriate in this context. Kaopectate is an anti-diarrheal medication, and using it would counteract the effect of lactulose, which aims to promote bowel movements to reduce ammonia levels.

Choice C reason: Instructing the patient to stop taking the medication until stools firm up is incorrect. Lactulose should be continued as prescribed to maintain its therapeutic effect of reducing blood ammonia levels. Stopping the medication would negate its benefits and potentially worsen the patient's condition.

Choice D reason: Suggesting to send a stool specimen to the laboratory is unnecessary in this scenario. Diarrhea is an expected side effect of lactulose, and there is no indication that a stool specimen needs to be analyzed unless there are signs of infection or other complications.