A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should identify that which of the following is the priority finding?

A) Hypertension: Phenelzine is a monoamine oxidase inhibitor (MAOI) used as an antidepressant medication. It works by inhibiting the breakdown of neurotransmitters such as serotonin, norepinephrine, and dopamine in the brain. When phenelzine is taken with foods high in tyramine, such as aged cheese, a potentially dangerous interaction can occur. Tyramine-rich foods can cause the release of stored catecholamines, leading to a sudden increase in blood pressure, known as a hypertensive crisis. Symptoms of a hypertensive crisis can include severe headache, palpitations, chest pain, nausea, vomiting, and sweating. Therefore, hypertension is a manifestation of the interaction between phenelzine and aged cheese.

B) Bradycardia: Bradycardia, or slow heart rate, is not typically associated with the interaction between phenelzine and aged cheese. Instead, the interaction is more commonly associated with a sudden increase in blood pressure (hypertension).

C) Somnolence: Somnolence, or drowsiness, is a common side effect of phenelzine but is not specifically related to the interaction between phenelzine and aged cheese.

D) Diarrhea: Diarrhea is not typically associated with the interaction between phenelzine and aged cheese. Instead, the interaction is more commonly associated with a sudden increase in blood pressure (hypertension).

B) Sepsis: Propofol is an intravenous sedative-hypnotic agent commonly used for sedation in mechanically ventilated patients. While propofol itself does not directly cause sepsis, its use can increase the risk of sepsis-related complications, such as infection. Propofol is typically administered intravenously, and improper handling or contamination of equipment, including intravenous lines and medication vials, can introduce pathogens into the bloodstream, leading to bloodstream infections (sepsis). Additionally, prolonged use of propofol may suppress immune function, further increasing the susceptibility to infection. Therefore, the nurse should monitor the client for signs and symptoms of sepsis, such as fever, chills, hypotension, tachycardia, and altered mental status, as a potential complication of propofol administration.

A) Hypokalemia: Hypokalemia, or low potassium levels, is not a common complication directly associated with propofol administration. While electrolyte imbalances may occur in critically ill patients, especially those receiving mechanical ventilation, hypokalemia is more likely to result from other factors such as diuretic therapy, gastrointestinal losses, or inadequate potassium intake.

C) Urinary retention: Urinary retention is not a typical complication of propofol administration. While sedative medications like propofol can affect bladder function, causing urinary retention in some cases, it is not a commonly reported complication of propofol use in mechanically ventilated patients.

D) Hypoglycemia: Hypoglycemia, or low blood sugar levels, is a potential complication of propofol administration, particularly in critically ill patients who may have altered glucose metabolism. However, hypoglycemia is not as commonly associated with propofol use as sepsis-related complications. Close monitoring of blood glucose levels is essential when administering propofol, especially if the client has preexisting diabetes mellitus or other risk factors for hypoglycemia. However, sepsis is a more direct and significant complication associated with propofol administration in mechanically ventilated patients.