The nurse is reviewing the assessment data of a patient taki…

The nurse is reviewing the assessment data of a patient taking spironolactone. Based on the findings below, which action would the nurse take? Select all that apply. One, some, or all responses may be correct. Assessment Data Alert and oriented X 4 Temperature 98.8°F Heart rate irregular at 120 beats/minute Respirations 22 breaths/minute Blood pressure 138/84 mm Hg Breath sounds diminished in bilateral bases Reports abdominal pain and diarrhea Peripheral pulses 2+ and strong bilaterally without edema 350 mL/24 hours dark amber urine