I think the priority action is to monitor Bowel movements.
Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If the client does not have stools, the drug cannot work properly. Blood pressure and the urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.
