The nurse is assessing the client following the transfusion of 2 units of packed RBCs.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding click on the finding again

 

Laboratory Results

1800

• WBC count 6700/mm3 15.000 to 10.000/mm
• Hemoglobin 12 g/dl (14 to 18 g/dL)
• Hematocrit 36% (40% to 52%)

Vital Signs

1800

• Blood pressure 112/74 mm Hg
• Heart rate 95/min
• Respiratory rate 18/
• Temperature 37.5°C (95°F)
• Oxygen saturation 100% via 2 L/min nasal cannula

 

Rationale:

A. History of severe menorrhagia: A copper IUD can increase menstrual bleeding and cramping. Clients with a history of severe menorrhagia are at higher risk for exacerbated bleeding and anemia, making this a contraindication to IUD insertion. Alternative contraceptive methods should be considered for these clients.

B. Desire to become pregnant in 1 to 2 years: While the client’s future fertility plans may influence contraceptive choice, it is not a medical contraindication. The IUD can be removed at any time, allowing fertility to return quickly, so this does not preclude insertion.

C. Takes antiretroviral therapy for HIV: HIV infection or antiretroviral therapy is not a contraindication to IUD use. Clients with HIV can safely use intrauterine contraception, provided there are no active pelvic infections.

D. Report of unprotected sex in the past 24 hr: Recent unprotected intercourse is not a contraindication, but the nurse should assess the risk of pregnancy and consider emergency contraception if appropriate. It does not medically prevent IUD insertion.

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.