A nurse is reviewing the laboratory findings of a client who has liver failure with ascites. The client takes spironolactone. Which of the following findings is an adverse effect of themedication?

A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.

B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.

The priority is to determine the client's immediate physiological status.

C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of

nausea and refusal of breakfast.

D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.