The nurse is caring for a 58-year-old client who was admitted to the medical unit with liver cirrhosis. The nurse is continuing with patient care, select all anticipated actions in the care of this patient.

Nursing management of a client with advanced liver cirrhosis focuses on preventing and managing complications such as ascites, anemia, gastrointestinal bleeding, and hemodynamic instability. This client presents with ascites, anemia, hypoalbuminemia, jaundice, and early signs of decompensation, indicating significant portal hypertension and reduced liver synthetic function. Care priorities include stabilization of fluid status, monitoring for bleeding risk, and preparation for both diagnostic and therapeutic interventions. Ongoing assessment is essential due to the risk of rapid clinical deterioration. A. Type and cross-match for 2 units of packed red blood cells is appropriate because the client is anemic (low hemoglobin and RBC count), likely due to chronic liver disease, possible gastrointestinal bleeding risk, and reduced erythropoietin response. Cirrhosis patients are at high risk for variceal bleeding due to portal hypertension. Preparing blood products ensures readiness for transfusion if acute bleeding occurs or hemoglobin levels worsen. B. Starting the client on a clear liquid diet is not appropriate because this client requires a low-sodium diet and possible fluid restriction due to ascites and fluid overload. Dietary management in cirrhosis focuses on sodium restriction to reduce fluid retention, not bowel rest or clear liquids. Unless there is an acute procedure requiring NPO status, clear liquids are not indicated. C. Transferring the client to the critical care unit is not indicated at this time because vital signs are currently stable and there is no evidence of acute respiratory failure, active massive hemorrhage, or hemodynamic collapse. Although the condition is serious, current data suggest a compensated or stabilized state. ICU transfer would be reserved for acute decompensation or bleeding events. D. Preparing the client for an endoscopic procedure is appropriate because cirrhosis with portal hypertension places the client at high risk for esophageal varices. Endoscopy is used to evaluate and potentially treat varices to prevent or manage life-threatening upper gastrointestinal bleeding. Given the anemia and cirrhosis history, diagnostic and prophylactic endoscopy is anticipated. E. Monitoring vital signs every 1–2 hours is necessary due to the risk of rapid hemodynamic changes in cirrhosis. The client has hypotension history, anemia, and risk for bleeding and fluid shifts from ascites. Frequent monitoring allows early detection of deterioration such as hypovolemic shock, infection, or internal bleeding. F. Preparing the client for paracentesis is appropriate because the client has significant ascites causing abdominal distention, discomfort, and respiratory compromise. Paracentesis helps remove excess peritoneal fluid, improving breathing and comfort. It is a common therapeutic procedure in decompensated cirrhosis with fluid overload.