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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is providing care for a client who is 44 hours postoperative following a percutaneous coronary intervention (PCI) via the right femoral artery. Which nursing action demonstrates the correct application of risk reduction principles?

  1. Promptly reporting to the registered nurse (RN) that the client's resting heart rate has gradually increased from 7676 to 112112 beats/minute.Answer
  2. B
    Administering a prescribed intravenous (IV) push analgesic to treat the client's sudden onset of lower back pain.
  3. C
    Waiting until the provider's evening rounds to report a newly resulted serum potassium level of 3.03.0 mEq/L (3.03.0 mmol/L).
  4. D
    Bypassing the electronic barcode scanning system to expedite the administration of a scheduled oral antiplatelet medication.

Answer

The correct action is to promptly report the increasing heart rate to the RN, as it is an early indicator of potential hemorrhage.
An unexplained, gradual increase in heart rate (tachycardia) following a femoral artery catheterization is a classic early sign of internal hemorrhage, such as a retroperitoneal bleed. The practical nurse demonstrates accurate application of risk reduction by recognizing this subtle vital sign change and immediately escalating it to the registered nurse for comprehensive assessment and intervention.

Step-by-Step Solution

1
Evaluate the client's current clinical data against baseline findings.
The heart rate has increased from 7676 to 112112 beats/minute.
Identifying trends in vital signs is crucial for detecting early physiological deterioration.
2
Correlate the vital sign changes with the client's recent surgical procedure.
The client had a femoral artery puncture, placing them at high risk for internal bleeding (retroperitoneal hemorrhage).
Unexplained, gradual tachycardia is one of the earliest compensatory mechanisms for hypovolemia or occult bleeding.
3
Determine the appropriate risk-reduction intervention within the PN scope of practice.
The PN must immediately escalate the finding to the supervising RN for further assessment and potential provider notification.
Early escalation allows for rapid medical intervention, preventing the client from progressing into severe hypovolemic shock.

Key Concept

Postoperative Complication Recognition and Scope of Practice
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Topics

Reduction of Risk Potential

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