A client with a history of cirrhosis due to hepatitis C presents to the emergency department with hematemesis and melena. The client is diagnosed with esophageal varices secondary to pulmonary hypertension. Which nursing intervention is the highest priority?

Pernicious anemiais a megaloblastic anemia caused by an autoimmune-mediated deficiency of intrinsic factor. This glycoprotein is secreted by gastric parietal cells and is essential for the absorption of cobalaminin the terminal ileum. Without intrinsic factor, dietary vitamin B12 cannot be utilized, leading to impaired DNA synthesis in erythrocytes and progressive, irreversible neurological degeneration.

Rationale:

A.Limiting citrus fruits is an incorrect dietary strategy for any form of anemia. Vitamin C found in citrus actually enhances the absorption of non-heme iron. While pernicious anemia is specifically a B12 issue rather than an iron issue, restricting these fruits provides no therapeutic benefit and could potentially impair general nutritional health.

B.Avoiding green leafy vegetables is inappropriate because these foods are rich in folate. Folate is another essential B vitamin required for red blood cell maturation. While folate cannot correct the vitamin B12 deficiency of pernicious anemia, it is a vital component of a balanced diet for hematologic health and should not be restricted.

C.Increasing fats and carbohydrates does not address the underlying pathophysiology of pernicious anemia. This condition is not a calorie-deficiency disorder but a specific micronutrient absorption failure. Promoting a high-fat or high-carbohydrate diet could lead to metabolic issues without improving the megaloblastic red blood cell production or the patient's neurological symptoms.

D.Increasing animal proteins like fish and meat indicates an understanding that vitamin B12is exclusively found in animal-derived foods. While patients with true pernicious anemia usually require lifelong parenteral injectionsbecause they cannot absorb oral B12, maximizing dietary intake is still taught as a supportive nutritional measure to ensure all available metabolic pathways are utilized.

Paracentesisis a procedure involving the aspiration of ascitic fluid from the peritoneal cavity. The rapid removal of several liters of protein-rich fluid can cause a significant interstitial-to-intravascular fluid shift, leading to post-paracentesis circulatory dysfunction. Monitoring for signs of hypovolemiaand decreased renal perfusion is critical to prevent acute kidney injury and cardiovascular collapse following the procedure.

Rationale:

A.A decrease in weight by 3 lb is an expected and desired outcome of paracentesis. Ascitic fluid is heavy, and its removal should result in an immediate reduction in the client's total body weight. This finding indicates that the procedure successfully removed a significant volume of fluid, helping to relieve abdominal pressure and discomfort.

B.A decrease in respiratory rate from 22 to 16 breaths/min is a positive sign. Large amounts of ascites put pressure on the diaphragm, causing shallow, rapid breathing. The removal of fluid decreases this intra-abdominal pressure, allowing for better lung expansion and more relaxed, efficient ventilation, which explains the improved respiratory rate.

C.A decrease in urine output to 20 mL/hr requires immediate action. Normal urine output should be at least 30 mL/hr. A drop below this level suggests decreased renal perfusiondue to a drop in intravascular volume after the fluid shift. This could indicate the onset of hypovolemic shock or hepatorenal syndrome, necessitating immediate fluid or albumin resuscitation.

D.A slight increase in blood pressure is generally not a cause for alarm immediately after a paracentesis. It may reflect the client's relief from the pain and respiratory distress caused by the ascites. As long as the pressure remains within a stable range, this finding does not indicate the acute circulatory failure that the nurse must prioritize.