On admission, the healthcare provider (HCP) prescribes a broad spectrum antibiotic for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription?

A. Administer a stool softener per PRN protocol: Constipation is a common side effect of opioid therapy, but it develops over time rather than immediately. While stool softeners should be initiated for prevention, they are not the priority at the start of an epidural infusion.

B. Insert an indwelling urinary catheter per protocol: Urinary retention can occur with epidural opioids, but it is a delayed complication. Catheter insertion may be necessary later but is not the immediate priority upon initiating the infusion.

C. Administer an antiemetic per PRN prescription: Nausea and vomiting can occur with opioids, but antiemetics are administered only if symptoms appear. Proactive monitoring for respiratory depression is more urgent at infusion initiation.

D. Apply a pulse oximeter to the client per protocol: Continuous epidural opioid infusions carry a risk of respiratory depression and hypoxemia. Applying a pulse oximeter allows for continuous oxygen saturation monitoring, enabling prompt detection of respiratory compromise.

• Hyperkalemia: The client’s symptoms of fatigue, muscle weakness, and diarrhea are classic signs of hyperkalemia, which can result from spironolactone use. This potassium-sparing diuretic decreases potassium excretion, increasing serum potassium levels that can impair muscle and nerve function.

• Hyperuricemia: Spironolactone rarely causes hyperuricemia, which involves increased uric acid levels and may lead to gout. The client’s current symptoms do not suggest gout or uric acid buildup, making this diagnosis less likely in this context.

• Hepatic failure: Liver failure typically presents with jaundice, ascites, altered mental status, and coagulopathy. The client’s symptoms of fatigue and diarrhea alone do not strongly indicate hepatic dysfunction, and there is no history or signs suggesting liver disease.

• Anemia: Fatigue is a common symptom of anemia, but muscle weakness and diarrhea are less directly linked. Without additional signs such as pallor or shortness of breath, anemia is less probable as the primary cause of her symptoms.

• Draw blood for a chemistry panel: This is essential to evaluate electrolyte imbalances, particularly serum potassium, and kidney function. A comprehensive chemistry panel will guide appropriate interventions and confirm if hyperkalemia is present.

• Do a point of care glucose check: Although glucose checks are important for patients with diabetes or hypoglycemia symptoms, the client’s presentation does not suggest blood sugar abnormalities as the cause of her symptoms.

• Measure the client’s abdominal girth: This assessment is relevant for detecting ascites in liver disease or fluid overload but is not indicated here, given the absence of abdominal symptoms or swelling.

• Ask the client about their diet: Dietary intake of potassium-rich foods can exacerbate hyperkalemia. Understanding her diet helps the nurse and healthcare provider manage potassium levels more effectively through education or dietary modifications.

• Check the client’s oxygen saturation: Oxygen saturation monitoring is important for respiratory issues but is not relevant here since the client does not show respiratory distress or hypoxia.

• Potassium level: Continuous monitoring of potassium is critical to detect hyperkalemia early and prevent complications such as cardiac arrhythmias or muscle paralysis. Treatment decisions rely on these lab values.

• Pedal pulses: Assessment of peripheral pulses is valuable in evaluating circulation but does not provide specific information regarding hyperkalemia or the client’s current symptoms.

• Edema: While edema may indicate fluid retention or heart failure, it is unrelated to hyperkalemia and the client’s presenting complaints, thus not a priority monitoring parameter.

• Skin color: Skin assessment is part of a general physical exam but does not give targeted information about electrolyte disturbances or the effects of spironolactone.

• Heart rhythm: Hyperkalemia can cause dangerous cardiac arrhythmias, including ventricular fibrillation or heart block. Continuous cardiac monitoring is vital to detect these changes early and allow prompt intervention.