A nurse is caring for a client with cirrhosis and portal hypertension. Which of the following complications should the nurse monitor for?

A. Antiretroviral therapy (ART), including dolutegravir and lamivudine, inhibits HIV replication, reducing viral load to undetectable levels, which is a primary goal of treatment. This aligns with the patient’s regimen, as suppressing viral load prevents disease progression and reduces transmission risk.

B. Dolutegravir and lamivudine can cause side effects such as headache, nausea, vomiting, and anorexia, which are well-documented in clinical data. Educating the patient about these potential effects is crucial for adherence and managing expectations.

C. ART does not have zero side effects. Clinical evidence shows dolutegravir and lamivudine can cause adverse effects, including gastrointestinal issues and, rarely, liver problems, making this statement incorrect for patient education.

D. While dolutegravir may cause insomnia in some patients, it is not a universal effect requiring nighttime dosing. The prescribed morning dose of dolutegravir is standard to optimize adherence and efficacy, making this statement incorrect.

E. Doubling a missed dose is incorrect and potentially harmful. ART regimens require consistent dosing; patients should take the missed dose as soon as remembered unless it’s close to the next dose, to avoid toxicity and maintain efficacy.

F. Taking ART with antacids is not recommended, as antacids can reduce dolutegravir absorption, decreasing its effectiveness. Patients should be advised to avoid antacids or follow specific timing guidelines, making this statement incorrect.

G. CD4+T cell counts are a key measure of ART effectiveness, as they reflect immune system recovery. Monitoring CD4+T counts every 3 months, as ordered, assesses treatment success, making this statement correct for patient education.

H. ART, including dolutegravir and lamivudine, does not cause wasting syndrome. Wasting syndrome is associated with untreated HIV or older regimens, not modern ART, making this statement incorrect for patient education.

Choice A reason: Frequent skin assessments allow early detection of pressure injury signs, such as non-blanchable redness or skin breakdown. By identifying at-risk areas like the sacrum or heels, nurses can implement preventive measures promptly. This reduces tissue ischemia from prolonged pressure, preventing progression to ulcers by ensuring timely intervention to protect skin integrity.

Choice B reason: Frequent turning and positioning relieve pressure on bony prominences, reducing ischemia and tissue damage. Repositioning every 2 hours promotes blood flow, preventing prolonged compression of capillaries, which leads to hypoxia and necrosis. This is a cornerstone of pressure injury prevention, especially in immobile patients with limited tissue perfusion.

Choice C reason: Optimizing nutrition ensures adequate protein and micronutrient intake, essential for tissue repair and maintenance. Malnutrition impairs collagen synthesis and immune function, increasing susceptibility to skin breakdown. Adequate caloric and protein intake supports skin integrity, reducing the risk of pressure injuries by enhancing tissue resilience and healing capacity.

Choice D reason: Maintaining the head of the bed at a 45-degree angle increases shear forces on the sacrum and coccyx, potentially exacerbating pressure injury risk. While it may aid respiratory function, it does not directly prevent pressure injuries and may contribute to skin breakdown in immobile patients due to increased frictional forces.

Choice E reason: Inspecting the sacrum for blanching is part of skin assessment but is not an intervention to reduce incidence. Blanching indicates intact capillary perfusion, but non-blanchable redness signals early damage. While useful for staging, it is a diagnostic step, not a preventive measure like repositioning or nutrition, which actively reduce pressure injury risk.