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Difficulty: Very hardPhysiological Adaptation

A practical nurse is monitoring a client who underwent a right femoral cardiac catheterization four hours ago. The client's baseline vital signs upon admission to the unit were blood pressure 132/80 mm Hg and heart rate 74 beats/min. Current vital signs reveal a blood pressure of 96/58 mm Hg and a heart rate of 114 beats/min. The client reports a new, deep aching pain in the right lower back. Inspection of the right groin reveals a dry, intact dressing with no visible hematoma. Which action should the practical nurse take first?

  1. Immediately notify the registered nurse of the vital sign changes and the location of the pain.Answer
  2. B
    Assess the client's bilateral pedal pulses, skin color, and capillary refill time.
  3. C
    Administer the prescribed as-needed analgesic medication for the reported back discomfort.
  4. D
    Elevate the head of the client's bed to a 45-degree angle to relieve the back pressure.

Answer

Immediately notify the registered nurse of the vital sign changes and the location of the pain.
The client is exhibiting signs of retroperitoneal bleeding, a critical complication of femoral artery access. The combination of systemic hypovolemia (tachycardia, hypotension) and localized back pain, even with a clean anterior insertion site, strongly indicates internal hemorrhage. The practical nurse's priority is to recognize this acute physiological deterioration and immediately escalate the findings to the registered nurse for rapid emergency intervention.

Step-by-Step Solution

1
Analyze the change in vital signs.
Blood pressure has dropped significantly (132/80 to 96/58) and heart rate has increased (74 to 114).
These trends are classic compensatory mechanisms for hypovolemic shock (fluid/blood loss).
2
Correlate vital signs with the physical assessment findings and client symptoms.
The client has a femoral access site (risk for bleeding), new back pain, and a clean exterior dressing.
Bleeding from a femoral puncture can track backward into the retroperitoneal space, causing back or flank pain without visible swelling at the groin site.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The data indicates an acute, life-threatening complication requiring immediate medical intervention.
The practical nurse must rapidly recognize acute deterioration and immediately escalate the findings to the registered nurse or provider for emergency management.

Key Concept

Recognition of retroperitoneal hemorrhage and hypovolemic shock post-cardiac catheterization.
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Topics

Physiological Adaptation

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