The nurse observes that a client has become lethargic 30 minutes after receiving an opioid injection for pain. Which vital sign should the nurse obtain first?

A. Serum ammonia level of 30 μg/dl (17.62 μmol/dL):
Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. It does not affect serum ammonia levels, which are more relevant in cases of liver dysfunction or urea cycle disorders. Thus, this finding does not indicate the effectiveness of the medication.
B. Hemoglobin level of 13.5 g/dL (135 g/L):
Hemoglobin levels are related to anemia or blood disorders and are not directly affected by sodium polystyrene sulfonate. This lab result would not indicate the effectiveness of the medication in managing potassium levels.
C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L):
Sodium polystyrene sulfonate is specifically used to lower elevated potassium levels. A serum potassium level within the normal range (3.5 to 5 mEq/L) indicates that the medication has been effective in reducing hyperkalemia, which is the primary goal of treatment with this drug.
D. Serum glucose level of 120 mg/dL (6.7 mmol/L):
While glucose levels are important for overall metabolic management, they are not directly impacted by sodium polystyrene sulfonate. This result would not reflect the effectiveness of the medication in treating elevated potassium levels in acute kidney injury.

A. Complete a medication variance report: This action is important if there is a concern about the medication’s impact or if the adverse effects might be related to an error in administration or dosage. Documenting and reporting these issues help ensure safety and provide information for evaluating the medication’s use.
B. Obtain a soft bristle toothbrush for client: Using a soft bristle toothbrush is a critical intervention to minimize gum trauma and bleeding, especially in clients on anticoagulants who are at higher risk for bleeding and gum tenderness. This helps reduce the risk of further bleeding and discomfort.
C. Report findings to healthcare provider: It is essential to inform the healthcare provider about the bleeding, tender gums, and bruising. These symptoms indicate potential complications related to the anticoagulant therapy that may require adjustment of the medication or additional interventions to manage the bleeding risk.
D. Provide a PRN NSAID for gum discomfort: NSAIDs (nonsteroidal anti-inflammatory drugs) should generally be avoided in clients on anticoagulants because they can further increase bleeding risk. Instead, other methods for managing discomfort should be considered, and this action could potentially exacerbate the bleeding issue.
E. Review most recent coagulation lab values: Checking the most recent coagulation lab values is important to assess whether the anticoagulant is at an appropriate level and to determine if adjustments are needed. This helps in managing and preventing further bleeding complications.