Examkin

Question

Difficulty: Very hardReduction of Risk Potential

A practical nurse is caring for a client who returned 3 hours ago following a percutaneous coronary intervention (PCI) via the right femoral artery approach. The client reports a new, deep aching pain in the right lower back. The right groin dressing is dry and intact, and bilateral pedal pulses are palpable. Current vital signs are: blood pressure 104/64 mm Hg (baseline 132/80 mm Hg), heart rate 102 bpm (baseline 74 bpm), and respiratory rate 18 breaths/min. Which of the following actions should the practical nurse take first?

  1. Notify the supervising registered nurse immediately of the assessment findings.Answer
  2. B
    Administer the prescribed as-needed acetaminophen to relieve the reported back pain.
  3. C
    Document the expected procedural discomfort and continue scheduled vital sign checks.
  4. D
    Assist the client to turn onto the left side to relieve pressure on the lower back.

Answer

The correct action is to notify the supervising registered nurse immediately of the assessment findings.
The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral artery catheterization. The combination of new lower back pain and subtle signs of hemodynamic compromise (mild tachycardia and decreased blood pressure from baseline) despite a dry insertion site requires immediate escalation to the registered nurse for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's symptoms in the context of the recent invasive procedure.
The client has new deep lower back pain 3 hours after a right femoral artery catheterization.
Back or flank pain after a femoral procedure is a cardinal sign of retroperitoneal hemorrhage, even if the external insertion site appears dry.
2
Compare the current vital signs against the client's baseline data.
The heart rate has increased from 74 to 102 bpm, and the blood pressure has decreased from 132/80 to 104/64 mm Hg.
Identifying subtle shifts in vital signs helps differentiate benign back pain from early hypovolemic shock caused by internal bleeding.
3
Synthesize the clinical data to determine the risk level.
The combination of back pain and borderline hypovolemic vital signs indicates a high risk for a life-threatening retroperitoneal hemorrhage.
Recognizing severe complications is necessary for safe risk reduction and prioritization.
4
Select the appropriate nursing intervention within the practical nurse scope of practice.
The practical nurse must immediately escalate the findings to the registered nurse or provider.
Life-threatening complications require immediate advanced assessment and intervention beyond the practical nurse scope.

Key Concept

Recognizing Retroperitoneal Hemorrhage
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic