Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medications

A. Monitor respiratory rate for anomalies: Respiratory rate should be monitored because instilled dialysate can increase intra-abdominal pressure, impairing diaphragmatic movement and leading to breathing difficulties.

B. Monitor blood pressure for fluctuations: Blood pressure must be assessed closely since fluid shifts during peritoneal dialysis can lead to hypotension or hypertension, reflecting fluid imbalance.

C. Check pulse oximetry regularly: Pulse oximetry is important because decreased lung expansion from abdominal fluid can cause hypoxemia, especially in patients with preexisting respiratory compromise.

D. Regularly check blood glucose levels: Blood glucose monitoring is primarily emphasized in diabetic patients, since glucose-containing dialysate can elevate levels, but it is not a standard vital signs parameter.

E. Assess urine output for changes: Urine output may decline in end-stage renal disease patients, but it is not considered part of routine vital signs monitoring during dialysis treatment.

F. Monitor daily weight for fluid retention: Daily weight is a critical measure of fluid balance, helping evaluate dialysis effectiveness and detect early signs of fluid overload or inadequate ultrafiltration.

G. Observe skin color and temperature changes: Monitoring skin color and temperature helps identify early signs of infection, hypoperfusion, or sepsis, making this an important component of vital signs assessment.

A. Hypertension: Hypertension is a frequent cardiovascular complication of kidney failure. Impaired renal function leads to sodium and fluid retention as well as activation of the renin-angiotensin-aldosterone system, all of which contribute to elevated blood pressure and increased cardiac workload.

B. Osteoporosis: Osteoporosis is a complication more closely associated with mineral and bone disorders in chronic kidney disease due to altered calcium and phosphate balance, but it is not considered a cardiovascular complication.

C. Atherosclerosis: Atherosclerosis can occur in patients with kidney failure, especially due to dyslipidemia and chronic inflammation, but hypertension is more directly and commonly linked as the primary cardiovascular complication.

D. Respiratory depression: Respiratory depression is not a cardiovascular complication. It may occur as a side effect of medications such as opioids or due to severe acidosis, but it is unrelated to the cardiovascular impact of kidney failure.