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Difficulty: HardReduction of Risk Potential

Following a percutaneous coronary intervention (PCI) via the right femoral artery, a client is transferred to the medical-surgical unit. During the 22-hour post-procedure assessment, the practical nurse evaluates the client's status. Which assessment findings suggest an impending clinical emergency requiring immediate notification of the registered nurse? Select all that apply.

  1. The client reports a new, deep, and persistent ache localized in the lower back and flank.Answer
  2. Blood pressure is 106/58 mm Hg106/58\text{ mm Hg} and heart rate is 118 bpm118\text{ bpm}, compared to a pre-procedure baseline of 136/78 mm Hg136/78\text{ mm Hg} and 82 bpm82\text{ bpm}.Answer
  3. A firm, localized, and tender swelling is palpable directly beneath the pressure dressing at the right groin insertion site.Answer
  4. D
    The client's oral temperature is 99.2∘F99.2^\circ\text{F} (37.3∘C37.3^\circ\text{C}) and the unlabored respiratory rate is 16 breaths per minute16\text{ breaths per minute}.
  5. E
    A 1.5-centimeter1.5\text{-centimeter} area of dry, dark brown drainage is noted on the dressing margins without any active, bright red oozing.
  6. F
    The client reports generalized stiffness and muscle fatigue in the right leg from maintaining a strict, flat supine position.

Answer

The findings requiring immediate escalation are the new onset of deep lower back/flank pain, the significant drop in blood pressure with tachycardia, and the palpable firm swelling at the insertion site.
Following a femoral artery procedure, clients are at high risk for vascular complications. A drop in blood pressure combined with tachycardia indicates hypovolemia, likely from internal bleeding. New, persistent back or flank pain is the classic presentation of a retroperitoneal hemorrhage. A firm, tender, expanding swelling at the puncture site indicates a developing hematoma. All of these are life-threatening emergencies requiring immediate manual pressure, RN notification, and provider intervention.

Step-by-Step Solution

1
Analyze the procedure and its associated risks.
The client underwent a femoral artery PCI, which carries high-risk potential for arterial bleeding, hematoma formation, and retroperitoneal hemorrhage.
Identifying procedure-specific risks directs the focused assessment priorities and defines what constitutes an emergency.
2
Evaluate each assessment finding against the expected post-operative baseline.
Back pain and dropping blood pressure indicate internal retroperitoneal bleeding. A firm mass indicates a local hematoma. A low-grade temperature, dry drainage, and muscle stiffness are expected, benign findings.
Discriminating between expected post-procedure recovery symptoms and emergent, life-threatening complications is critical for appropriate risk reduction and timely RN escalation.

Key Concept

Recognition of vascular complications (hemorrhage, hematoma, and retroperitoneal bleeding) following femoral arterial access.
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Reduction of Risk Potential

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