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Difficulty: HardPhysiological Adaptation

Following a percutaneous coronary intervention via the right femoral artery, a 74-year-old client is admitted to the telemetry unit for observation. Six hours later, the client becomes highly agitated, complains of severe, deep lower back pain, and insists on getting out of bed to void. The client's heart rate has increased from a baseline of 78 bpm to 110 bpm, and blood pressure has dropped from 130/76 mmHg to 102/64 mmHg. Which action should the practical nurse (PN) take first?

  1. Instruct the client to remain strictly flat in bed and immediately notify the registered nurse (RN).Answer
  2. B
    Offer the client a urinal and assist with minor position changes to relieve the back pain.
  3. C
    Document the vital signs and reassure the client that back pain is a common side effect of prolonged bed rest.
  4. D
    Assess the client's orientation and request a prescription for a mild sedative to prevent disruption of the puncture site.

Answer

Instruct the client to remain strictly flat in bed and immediately notify the registered nurse (RN).
The client is exhibiting classic signs of a retroperitoneal hemorrhage (severe back pain, agitation, tachycardia, and hypotension) following a femoral artery puncture. The correct answer identifies the urgent need to maintain the flat position to prevent further arterial bleeding and immediately escalate the situation to the RN for advanced emergency management.

Step-by-Step Solution

1
Analyze the client's recent procedure and associated risk factors.
The client underwent a femoral cardiac catheterization, which carries a high risk for arterial bleeding and hematoma formation at the puncture site.
Understanding procedure-specific complications directs the targeted assessment.
2
Evaluate the new onset symptoms.
Severe lower back or flank pain combined with agitation are classic signs of a retroperitoneal hemorrhage, where blood pools internally behind the abdominal cavity.
Identifying hallmark symptoms distinguishes life-threatening complications from routine discomfort.
3
Interpret the vital sign trends.
The increase in heart rate to 110 bpm and drop in blood pressure to 102/64 mmHg indicate early compensated hypovolemic shock.
Objective data confirms the subjective reports of distress and points directly to internal blood loss.
4
Determine the priority PN action.
The PN must prevent further bleeding by keeping the patient flat and immediately escalate care to the RN for emergency medical intervention.
Acute hemorrhage requires rapid medical management (e.g., fluids, blood products, surgical intervention) that is beyond the scope of independent PN practice.

Key Concept

Recognition and Prioritization of Retroperitoneal Hemorrhage
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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