Examkin

Question

Difficulty: HardPhysiological Adaptation

A client is recovering on the telemetry unit four hours after a percutaneous coronary intervention performed through the right femoral artery. When the practical nurse enters the room, the client complains of a new, persistent dull ache in the lower back and right flank. Current vital signs include a heart rate of 106 beats/min and a blood pressure of 104/64 mm Hg, compared to a pre-procedure baseline of 78 beats/min and 126/78 mm Hg. The femoral insertion site dressing remains clean, dry, and intact. Which action should the nurse take first?

  1. Escalate the findings immediately to the registered nurse due to the risk of internal hemorrhage.Answer
  2. B
    Administer the prescribed as-needed analgesic to relieve the client's reported back discomfort.
  3. C
    Document the findings and continue routine hourly monitoring since the insertion site is free of bleeding.
  4. D
    Assist the client into a side-lying position to decrease pressure and tension on the lumbar spine.

Answer

The correct action is to escalate the findings immediately to the registered nurse due to the risk of internal hemorrhage.
The correct answer identifies the need for immediate escalation. A client who has undergone a femoral cardiac catheterization is at high risk for a retroperitoneal hemorrhage. Because the bleeding occurs internally into the retroperitoneal space, the external femoral dressing will often appear dry and intact. The classic signs of this severe complication are new-onset lower back or flank pain, accompanied by early signs of hypovolemic shock, such as an increasing heart rate and a decreasing blood pressure. The practical nurse must recognize this acute physiological deterioration and immediately escalate the findings to the registered nurse or provider for rapid intervention.

Step-by-Step Solution

1
Analyze the client's history and current symptoms.
The client had a right femoral artery procedure and now has new right flank and back pain.
Identifying the procedure type helps anticipate specific complications, such as retroperitoneal bleeding.
2
Evaluate the vital sign trends against the baseline.
The heart rate has increased from 78 to 106 beats/min, and blood pressure has dropped from 126/78 to 104/64 mm Hg.
Comparing current vitals to baseline reveals early hemodynamic instability and signs of hypovolemic shock.
3
Correlate the physical findings to determine the clinical priority.
Despite a dry external dressing, the combination of flank pain, tachycardia, and hypotension points to internal retroperitoneal hemorrhage.
Internal bleeding is a life-threatening physiological complication that requires immediate medical intervention.
4
Select the nursing action that addresses the highest priority.
The nurse must immediately notify the registered nurse.
The practical nurse scope of practice requires escalating unstable clients and critical complications to the registered nurse for advanced assessment and intervention.

Key Concept

Recognition of Retroperitoneal Hemorrhage
Rate this question

Topics

Physiological Adaptation

More questions from this topic