D. All of the above

This is because indomethacin can cause gastrointestinal, renal, and cardiovascular effects as a result of its nonselective inhibition of cyclooxygenase (COX) enzymes². COX enzymes are responsible for producing prostaglandins that have different functions in different tissues. By blocking both COX-1 and COX-2 enzymes, indomethacin can interfere with the protective, regulatory, and homeostatic roles of prostaglandins in various organs². Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat gout and other inflammatory conditions by reducing pain, swelling, and joint stiffness¹. It works by blocking the production of prostaglandins, which are chemical messengers that cause inflammation and pain¹. However, it can also cause some adverse effects that the nurse should watch for.

1. Gastrointestinal effects such as nausea, vomiting, ulceration, bleeding, and perforation

These are the most common and serious side effects of indomethacin and other NSAIDs²³. They occur because indomethacin blocks the production of prostaglandins that protect the gastric mucosa from acid and pepsin, maintain the mucosal blood flow, and promote healing of ulcers². The risk of these effects is higher in older adults, those with a history of peptic ulcer disease or gastrointestinal bleeding, those who use alcohol or tobacco, and those who take other drugs that irritate the stomach, such as corticosteroids or anticoagulants²³. The nurse should advise the client to take indomethacin with food or milk, avoid alcohol and tobacco, report any signs of gastrointestinal bleeding (such as black or tarry stools, abdominal pain, vomiting blood), and use the lowest effective dose for the shortest duration possible²³.

1. Renal effects such as reduced glomerular filtration rate, sodium and water retention, edema, hypertension, and acute renal failure

These are less common but potentially serious side effects of indomethacin and other NSAIDs²⁴. They occur because indomethacin blocks the production of prostaglandins that regulate renal blood flow, glomerular filtration rate, sodium excretion, and water balance². The risk of these effects is higher in those with preexisting renal impairment, heart failure, liver cirrhosis, dehydration, or hypovolemia, and those who use diuretics or angiotensin-converting enzyme inhibitors²⁴. The nurse should monitor the client's fluid intake and output, body weight, blood pressure, electrolytes, and renal function tests, and report any signs of renal dysfunction (such as oliguria, anuria, edema) or worsening heart failure (such as dyspnea, fatigue) to the doctor²⁴.

1. Cardiovascular effects such as increased risk of myocardial infarction and stroke due to platelet aggregation and vasoconstriction

These are rare but potentially fatal side effects of indomethacin and other NSAIDs²⁵. They occur because indomethacin blocks the production of prostaglandins that inhibit platelet aggregation and vasodilation². The risk of these effects is higher in those with a history of cardiovascular disease or risk factors such as hypertension, diabetes mellitus, hyperlipidemia, smoking, or obesity²⁵. The nurse should assess the client's cardiovascular status and history before starting indomethacin therapy and advise the client to seek immediate medical attention if they experience any signs of a heart attack (such as chest pain or pressure) or a stroke (such as sudden weakness or numbness on one side of the body) while taking this drug²⁵.