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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is assessing a client who is 4 hours post-procedure following a cardiac catheterization using a right femoral artery approach. The client's baseline vital signs were blood pressure 142/86 mm Hg and heart rate 74 beats/min. During the current assessment, the client reports a new onset of a mild, continuous ache in the lower back. The current vital signs are blood pressure 114/72 mm Hg and heart rate 98 beats/min. Which action should the PN take first?

  1. A
    Administer the prescribed PRN oral analgesic for the back ache.
  2. B
    Assist the client into a side-lying position to relieve the back discomfort.
  3. Immediately notify the registered nurse (RN) of the assessment findings.Answer
  4. D
    Document the vital signs and continue scheduled monitoring.

Answer

Immediately notify the registered nurse (RN) of the assessment findings.
The correct action is to immediately notify the RN. The combination of a downward trend in blood pressure, an increasing heart rate, and new-onset lower back pain following a femoral cardiac catheterization is a classic presentation of a retroperitoneal hemorrhage. This is a medical emergency requiring rapid intervention, and the LPN must escalate these findings immediately to ensure client safety.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to the baseline.
The blood pressure has decreased from 142/86 mm Hg to 114/72 mm Hg, and the heart rate has increased from 74 beats/min to 98 beats/min.
Identifying trends in vital signs helps detect early systemic complications such as fluid volume deficit or impending shock.
2
Evaluate the new symptom of lower back ache in the context of the recent procedure.
The client had a cardiac catheterization via the femoral artery. Lower back pain combined with a decreasing blood pressure and an increasing heart rate indicates a potential retroperitoneal hemorrhage.
Internal bleeding from the femoral puncture site can pool in the retroperitoneal space, causing back pain without any obvious external bleeding.
3
Determine the appropriate nursing intervention within the LPN scope of practice.
The priority action is to immediately escalate these critical assessment findings to the RN or healthcare provider.
A suspected internal hemorrhage is a life-threatening complication that requires advanced assessment and rapid intervention beyond the LPN scope of practice.

Key Concept

Early Recognition and Escalation of Hemorrhagic Complications Post-Cardiac Catheterization
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Topics

Reduction of Risk Potential

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