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Difficulty: MediumReduction of Risk Potential

A client is admitted to the progressive care unit following a cardiac catheterization utilizing a right femoral artery approach. Four hours after the procedure, the practical nurse obtains a blood pressure of 92/58 mmHg92/58 \text{ mmHg} and a heart rate of 114 beats per minute114 \text{ beats per minute}. The client exhibits mild pallor and reports feeling dizzy, but denies any localized groin pain or chest pressure. What is the priority nursing action?

  1. Promptly report the current hemodynamic findings and client symptoms to the supervising registered nurse.Answer
  2. B
    Record the measurements and plan to recheck the client's vital signs at the next scheduled rounding interval.
  3. C
    Prepare to administer an as-needed oral analgesic, anticipating that the tachycardia is related to procedural soreness.
  4. D
    Assist the client into a seated, high-Fowler's position to help alleviate the sensation of dizziness.

Answer

Promptly report the current hemodynamic findings and client symptoms to the supervising registered nurse.
The client is exhibiting early signs of hypovolemic shock or potential internal bleeding, indicated by hypotension, tachycardia, pallor, and dizziness following a femoral artery puncture. The practical nurse must prioritize circulation and patient safety by immediately reporting these abnormal findings to the registered nurse or healthcare provider for further assessment and intervention.

Step-by-Step Solution

1
Analyze the client's current vital signs and symptoms in the context of the recent invasive procedure.
The blood pressure of 92/58 mmHg and heart rate of 114 beats per minute, combined with pallor and dizziness, indicate potential fluid volume deficit.
Recognizing early signs of complications is essential for preventing severe deterioration, such as hypovolemic shock from a femoral or retroperitoneal bleed.
2
Evaluate the nursing scope of practice for the identified potential complication.
The practical nurse identifies that these unstable, deteriorating findings require immediate advanced assessment and potential medical orders.
Practical nurses must promptly report critical changes in a client's condition to the supervising registered nurse or healthcare provider.
3
Determine the priority intervention among the given choices.
Escalating the findings immediately is the safest and most appropriate action.
Timely reporting ensures the client receives prompt medical intervention to manage a potential post-procedure hemorrhage.

Key Concept

Recognizing and Escalating Early Signs of Post-Procedure Hemorrhage
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Topics

Reduction of Risk Potential

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