A nurse is caring for a client who ingested a toxic amount of acetaminophen 36 hr ago.
Which of the following findings should the nurse monitor? Select all that apply.

Choice A rationale

Magnesium levels within the normal range of 1.3 to 2.1 mEq/L do not directly indicate a therapeutic response to sodium polystyrene sulfonate. This medication is primarily used to exchange potassium ions for sodium ions in the gastrointestinal tract, thus lowering serum potassium. Magnesium homeostasis is regulated independently, often by renal excretion and dietary intake, and is not a direct target of this drug.

Choice B rationale

Calcium levels within the normal range of 9 to 10.5 mg/dL do not indicate a therapeutic response to sodium polystyrene sulfonate. This medication does not significantly impact calcium metabolism. Calcium regulation involves parathyroid hormone and vitamin D, and is separate from the ion-exchange mechanism of sodium polystyrene sulfonate.

Choice C rationale

Sodium levels within the normal range of 136 to 145 mEq/L, while desirable, do not directly indicate a therapeutic response to sodium polystyrene sulfonate. Although the medication exchanges potassium for sodium, leading to a potential increase in serum sodium, the primary therapeutic goal is potassium reduction, and a normal sodium level alone does not confirm this.

Choice D rationale

A potassium level of 4.8 mEq/L, which falls within the normal range of 3.5 to 5 mEq/L, indicates a therapeutic response to sodium polystyrene sulfonate. This medication functions as a cation-exchange resin, binding to potassium ions in the intestine and facilitating their excretion, thereby lowering elevated serum potassium levels to a safe range.

Choice A rationale

Constipation is a very common and expected adverse effect of codeine due to its opioid effects on gastrointestinal motility, specifically by decreasing propulsive contractions. While it requires management, it is generally not the highest priority unless it leads to severe complications like impaction, making other acute symptoms more immediately concerning. Normal bowel frequency varies but ranges from three times daily to three times weekly.

Choice B rationale

Dry mouth, or xerostomia, is a common anticholinergic-like effect of opioid medications like codeine. While uncomfortable, it is typically a mild, non-life-threatening side effect. It can be managed with hydration and oral hygiene measures and does not represent an acute physiological threat requiring immediate reporting as a priority.

Choice C rationale

Agitation, especially in the context of opioid use, can be a sign of central nervous system excitation or an idiosyncratic reaction. It can indicate a paradoxical effect of the medication or an emerging adverse event that could escalate to more serious neurological complications, such as seizures or respiratory compromise if not promptly addressed.

Choice D rationale

Urinary retention is a known adverse effect of opioids due to their effect on bladder detrusor muscle tone and sphincter function. While it is important to monitor and manage, potentially requiring catheterization, it is generally not as immediately life-threatening as signs of central nervous system instability or respiratory compromise, making agitation a higher priority in the acute setting.