A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
Reduce the client's intake of protein.
Restrict the client's intake of fluids.
Administer vitamin K
Administer diuretics.
The Correct Answer is A
A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.
B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.
C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.
D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.
B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.
C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.
D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.
Correct Answer is A
Explanation
A. The first action should be to discontinue the existing IV line to prevent further damage and reduce the risk of complications, such as phlebitis or infiltration.
B. Initiating a new IV line is necessary, but it should be done after addressing the issue with the current IV site.
C. Applying a hot pack might help with comfort, but addressing the cause of the irritation (discontinuing the IV) is more critical first.
D. Determining if the client needs to continue IV therapy is important but should follow the immediate step of addressing the current IV site issue.
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