The nurse is collecting data from the client following the transfusion of 2 units of packed RBCs.

Exhibits

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Laboratory Results:

1800:

WBC count 6,700/mm (5,000 to 10,000/mm3)

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/min

Temperature 37.5°  C (99.5°  F)

O2 saturation 100% 2 L/min O2 via nasal cannula

Assessment:

1800:

Physical Exam

General: no distress

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding

Neurologic: awake and alert

A. Current medications. The client is taking ibuprofen 800 mg three times daily, which is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastric mucosal injury, leading to peptic ulcers and gastrointestinal bleeding. Given the client's symptoms and history of dark, tarry stools, the use of NSAIDs requires immediate follow-up to prevent further complications.
B. Respiratory rate. The client’s respiratory rate is 18/min, which is within the normal range (12 to 20/min). This finding does not require immediate follow-up.
C. WBC count. The WBC count is 6,700/mm³, which falls within the normal range (5,000 to 10,000/mm³). There is no indication of an active infection or leukocytosis requiring urgent intervention.
D. Heart rate. The heart rate is 118/min, which is elevated and suggests tachycardia. This could be a compensatory response to hypovolemia from gastrointestinal bleeding. Immediate follow-up is necessary to prevent hemodynamic instability.
E. Stool results. The stool test is positive for occult blood, indicating gastrointestinal bleeding. This finding requires immediate follow-up to determine the severity of bleeding and prevent further blood loss.
F. Temperature. The client’s temperature is 37.5°C (99.5°F), which is within the normal range. There is no indication of fever or infection, so this does not require immediate intervention.
G. Blood pressure. The blood pressure is 90/50 mm Hg, which is low and may indicate hypovolemia due to gastrointestinal blood loss. Hypotension combined with tachycardia is a concerning sign that requires urgent intervention.
H. Hemoglobin and hematocrit. The hemoglobin (9.1 g/dL) and hematocrit (27%) are low, suggesting anemia likely due to chronic blood loss. This requires immediate follow-up to assess for continued bleeding and the need for interventions such as fluid resuscitation or blood transfusion.

A. "The headaches should decrease as you get used to the medication." Isosorbide dinitrate is a nitrate that causes vasodilation, leading to headaches due to increased blood flow and vessel expansion. These headaches are common, especially when starting therapy, but usually diminish as the body adjusts. Clients can use mild analgesics, such as acetaminophen, if needed.
B. "You can discontinue the medication until the headache goes away." Stopping isosorbide dinitrate abruptly can lead to rebound angina or worsened ischemic symptoms. Instead, the client should continue the medication as prescribed and manage headaches with analgesics or dosage adjustments as directed by the provider.
C. "Swallow the tablet whole to minimize your headaches." Isosorbide dinitrate comes in various formulations, including chewable, sublingual, and extended-release tablets. Chewable or sublingual forms are designed for rapid absorption, while extended-release tablets should be swallowed whole. However, swallowing the tablet whole does not prevent headaches, as the vasodilatory effect remains the same.
D. "You should take the medication on an empty stomach to prevent a headache." Taking isosorbide dinitrate with or without food does not significantly impact the likelihood of headaches. Food can delay absorption slightly but does not prevent vasodilation-related headaches. Adjusting the dosing schedule or using analgesics is more effective for managing this side effect.