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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is monitoring a client who returned to the unit two hours ago following a cardiac catheterization via the right femoral artery. The client is resting quietly and denies any discomfort. The PN obtains the following vital signs: heart rate 116 beats/min, blood pressure 96/60 mm Hg, and respiratory rate 16 breaths/min. The client's pre-procedure blood pressure was 136/82 mm Hg. Which action should the PN take first?

  1. Examine the right groin insertion site and the linens beneath the client.Answer
  2. B
    Document the vital signs in the electronic health record and continue routine monitoring.
  3. C
    Ask the client to rate any pain at the catheterization insertion site on a 0 to 10 scale.
  4. D
    Elevate the head of the bed to a high-Fowler's position to promote patient comfort.

Answer

The practical nurse should first examine the right groin insertion site and the linens beneath the client for signs of bleeding.
Following a femoral cardiac catheterization, the sudden onset of tachycardia and a drop in blood pressure are early physiological indicators of hemorrhage (either external bleeding at the site or internal retroperitoneal bleeding). The practical nurse must immediately collect focused data by inspecting the insertion site and the linens underneath the client's back for pooling blood. This crucial information must be gathered before immediately escalating the findings to the registered nurse or healthcare provider.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to baseline data.
The client has developed sudden tachycardia (116 beats/min) and mild hypotension (96/60 mm Hg from 136/82 mm Hg).
Recognizing subtle signs of hemodynamic instability is critical for early intervention.
2
Relate the clinical findings to the recent surgical procedure.
Cardiac catheterization via the femoral artery carries a high risk of external bleeding or internal retroperitoneal hemorrhage.
Understanding procedure-specific complications guides focused data collection.
3
Determine the priority nursing action within the practical nurse scope of practice.
The PN must immediately inspect the insertion site and surrounding area to identify the source of potential bleeding.
Identifying active bleeding is essential for prioritizing Circulation (ABC) before escalating the findings to the registered nurse.

Key Concept

Prioritizing data collection for hemorrhage post-cardiac catheterization
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Topics

Physiological Adaptation

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