A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

Rationale:

A. Decreased inflammation: Furosemide is a loop diuretic that reduces fluid volume by promoting diuresis. While reducing edema may decrease swelling, “decreased inflammation” is not the primary measure of effectiveness for furosemide, as inflammation involves cellular processes rather than fluid removal.

B. Increased blood pressure: Furosemide typically lowers blood pressure by reducing circulating fluid volume. An increase in blood pressure would suggest the medication is not effective or another underlying issue is present, so this is not an expected finding.

C. Decreased pain: Pain reduction may occur indirectly if edema is relieved, but it is not a direct indicator of furosemide’s effectiveness. Pain levels are subjective and can be influenced by multiple factors, making this a less reliable measure.

D. Weight loss: A reduction in body weight reflects fluid loss, which is the primary therapeutic effect of furosemide. Monitoring daily weights is a standard and objective way to evaluate the effectiveness of diuretic therapy in clients with fluid volume excess.

Rationale for correct choices

• Osteomyelitis: The client has an open fracture, which increases the risk of infection in the bone due to direct exposure to pathogens. The rising temperature (36.8 → 38.9°C) and elevated heart rate indicate a possible inflammatory response, making monitoring for osteomyelitis essential. Early detection allows prompt initiation of antibiotics and prevents chronic bone infection.

• Fat embolism syndrome: The client sustained a long-bone fracture (right femur), which is a known risk factor for fat embolism syndrome. Signs such as tachycardia, tachypnea, and decreased oxygen saturation (96% → 94%) may indicate early fat emboli. Prompt recognition and supportive interventions, including oxygen therapy and monitoring respiratory status, are critical.

Rationale for incorrect choices

• Deep vein thrombosis (DVT): While immobility and trauma increase the risk of DVT, there is no evidence of unilateral leg swelling, redness, or pain reported in this client. Although preventive measures are important, current findings suggest infection and respiratory complications are more immediate risks.

• Compartment syndrome: Compartment syndrome typically presents with severe pain unrelieved by medication, tense swelling, and neurovascular compromise in the affected limb. The client’s report and vital signs do not indicate these specific signs, so it is not the most immediate concern at this time.