67. The goal of care for a client with liver failure is to lower the blood ammonia level. Which actions would prevent increased ammonia? Select all that apply.
67. The goal of care for a client with liver failure is to lower the blood ammonia level. Which actions would prevent increased ammonia? Select all that apply.
. Prevent gastrointestinal bleeding.
. Reduce dietary protein intake.
. Avoid diarrhea and vomiting.
. Decrease bacterial flora in the intestines.
. Prevent ascites.
Test-Taking Tip
Review how ammonia forms in the presence of blood and bacteria.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Illness Management
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Answer 1 is correct because ammonia is a by-product of protein breakdown by the intestinal flora. Blood is a source of protein. Answer 2 is correct because ammonia is a by-product of protein breakdown. Reducing dietary protein will decrease the ammonia level. Answer 3 is incorrect because diarrhea actually decreases ammonia and may be a desired therapeutic effect. Answer 4 is correct because protein is broken down to form ammonia by intestinal bacteria. Sterilizing the bowel with an antibiotic will decrease the ammonia level. Answer 5 is incorrect because the ammonia is produced in the GI system by the breakdown of protein. Ascites is in the peritoneum, not in the intestine.