Examkin

Question

Difficulty: MediumReduction of Risk Potential

A practical nurse is evaluating a client who underwent a percutaneous coronary intervention via the right femoral approach two hours ago. The client reports a new sensation of right flank fullness. The client's heart rate is 114 beats per minute and blood pressure is 92/58 mm Hg. The femoral insertion site dressing is completely dry. Which action should the nurse take first?

  1. Escalate the clinical findings to the supervising registered nurse without delay.Answer
  2. B
    Offer the client a prescribed as-needed oral analgesic for the flank fullness.
  3. C
    Elevate the head of the client's bed to 45 degrees to improve comfort.
  4. D
    Increase the intravenous fluid infusion rate independently to address the low blood pressure.

Answer

The nurse must escalate the clinical findings to the supervising registered nurse without delay.
The correct action is to immediately report the findings. Flank pain, tachycardia, and hypotension following a femoral arterial procedure are classic signs of retroperitoneal hemorrhage. Because the bleeding is internal, the external dressing remains dry. This is a life-threatening emergency that requires immediate medical intervention, making escalation the priority action for a practical nurse.

Step-by-Step Solution

1
Analyze the client's symptoms and vital signs.
The client has right flank fullness, tachycardia (114 beats per minute), and hypotension (92/58 mm Hg).
Identifying abnormal clinical data is the first step in recognizing potential complications.
2
Correlate the findings with the recent procedure (right femoral approach percutaneous coronary intervention).
The combination of flank pain and signs of hypovolemic shock after a femoral procedure strongly suggests retroperitoneal bleeding, even if the external dressing is dry.
Understanding procedural risks allows the nurse to interpret the meaning of the assessment data.
3
Determine the appropriate nursing action within the practical nurse scope of practice.
The practical nurse must immediately report these critical findings to the registered nurse or healthcare provider.
Life-threatening complications require immediate escalation for medical intervention.

Key Concept

Recognizing and escalating signs of retroperitoneal hemorrhage following femoral artery access.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic