The nurse is caring for a 58-year-old client who was admitted to the medical unit with liver cirrhosis. The nurse reviews the client history physical, vital signs and laboratory findings. Indicate whether the following interventions are indicated or not indicated.

This question focuses on prioritizing nursing interventions for a client with advanced liver cirrhosis complicated by ascites, hypoxemia risk, hypoalbuminemia, and anemia. Cirrhosis leads to fluid overload in the abdomen, impaired oxygenation due to diaphragmatic pressure, and hematologic abnormalities such as anemia and coagulopathy. Nursing care prioritizes fluid management, respiratory support, and monitoring for bleeding or infection. Interventions must be selected based on physiologic need and safety in liver failure. Rationale for correct choices: • Increase supplemental oxygen flow rate: The client’s oxygen saturation improved from 94% to 96% on 4 L/min nasal cannula, indicating adequate oxygenation at the current rate. Increasing oxygen unnecessarily may not provide additional benefit and could mask underlying respiratory compromise. The priority is addressing fluid overload and ascites rather than escalating oxygen therapy. Therefore, no increase in oxygen is indicated at this time. • Discontinue intravenous (IV) fluids: The client has severe ascites, low albumin, and fluid overload secondary to liver cirrhosis. Continued IV fluids can worsen third spacing and abdominal distention, increasing respiratory compromise. Fluid restriction is already prescribed, supporting the need to minimize additional fluid intake. Therefore, discontinuing IV fluids is appropriate. • Draw complete blood count STAT: The client has low hemoglobin and RBC count, indicating anemia likely due to chronic disease and possible occult bleeding. Liver cirrhosis also increases the risk for coagulopathy and infection. A STAT CBC helps evaluate trends in hemoglobin, hematocrit, and WBC count. This is important for early detection of bleeding or infection. • Insert nasogastric tube (NGT) to low suction: NG tube insertion is not appropriate in this client without evidence of gastrointestinal obstruction, bleeding, or aspiration risk requiring decompression. In liver cirrhosis, esophageal varices may be present, and NGT insertion can increase risk of variceal rupture and bleeding. There is no indication of vomiting or gastric distention requiring suction. Therefore, this intervention is unsafe and not indicated.