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Difficulty: HardReduction of Risk Potential

A practical nurse is caring for a client who underwent a diagnostic cardiac catheterization via the right femoral artery 3 hours ago. Upon assessment, the client reports new-onset, severe right lower back pain. The nurse observes that the client is mildly restless, with a heart rate of 114 beats/min and a blood pressure of 96/58 mm Hg. Which action should the practical nurse take first?

  1. Notify the registered nurse immediately while keeping the client in a flat, supine position.Answer
  2. B
    Administer the prescribed as-needed oral analgesic to relieve the client's back discomfort.
  3. C
    Elevate the head of the bed to a high-Fowler's position to help decrease the client's restlessness.
  4. D
    Reassure the client that lower back pain is an expected finding from lying flat on the procedural table.

Answer

The priority action is to immediately notify the registered nurse while maintaining the client in a flat, supine position.
The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral cardiac catheterization where blood leaks into the retroperitoneal space. Symptoms include severe back or flank pain, restlessness, tachycardia, and hypotension. To reduce risk potential, the practical nurse must prioritize circulation by keeping the client flat to minimize stress on the femoral puncture site and immediately notify the registered nurse for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's symptoms and vital signs.
The client has severe lower back pain, restlessness, tachycardia (114 beats/min), and mild hypotension (96/58 mm Hg).
Identifying abnormal clinical indicators is the first step in recognizing postoperative complications.
2
Correlate the findings with the recent femoral artery procedure.
The combination of back/flank pain and early signs of shock strongly indicates a retroperitoneal hemorrhage, a critical complication of a femoral puncture.
Connecting data points allows the nurse to prioritize physiological needs based on the risk of rapid deterioration.
3
Determine the safest immediate nursing action within the practical nurse scope of practice.
The nurse must keep the client flat to prevent disruption of the femoral clot and immediately report the critical findings to the registered nurse.
Life-threatening complications require immediate escalation to the registered nurse or provider for advanced interventions (e.g., fluid resuscitation, surgical evaluation).

Key Concept

Recognizing and Escalating Post-Procedural Hemorrhage
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Topics

Reduction of Risk Potential

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