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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.

A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis B. Suction the tube every 2 hr and as needed to maintain patency C. Maintain constant observation while the balloons are inflated D. Keep the head of the bed flat at all times to prevent the development of shock

Correct Answer is C

Explanation

A. Deflating the balloons regularly is not a standard practice and could potentially lead to rebleeding; balloon inflation should be managed carefully as per protocol.
B. Suctioning the tube should be done based on the need for patency, but every 2 hours might not be necessary unless indicated.
C. Maintaining constant observation while the balloons are inflated is crucial to monitor for complications such as esophageal tissue necrosis and to ensure effective hemostasis.
D. The head of the bed should typically be elevated to reduce the risk of aspiration and facilitate breathing, rather than kept flat.

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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?

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