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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is caring for a client who returned 2 hours ago from a diagnostic cardiac catheterization performed via the right femoral artery. The client's pre-procedure vital signs were a blood pressure of 138/76 mmHg and a heart rate of 72 beats/min. The client now reports a new onset of dull, aching pain in the lower right back. Current vital signs are blood pressure 102/58 mmHg, heart rate 108 beats/min, and respiratory rate 18 breaths/min. Which of the following actions is the priority for the PN to take?

  1. Immediately report the assessment findings to the registered nurse.Answer
  2. B
    Document the vital signs and continue to monitor the client every 15 minutes.
  3. C
    Assist the client into a high-Fowler's position to alleviate the back discomfort.
  4. D
    Perform a comprehensive physical assessment to determine the source of the back pain.

Answer

Immediately report the assessment findings to the registered nurse.
The client's new-onset tachycardia, relative hypotension, and lower back pain strongly indicate retroperitoneal bleeding, a severe and potentially life-threatening complication of a femoral cardiac catheterization. The practical nurse must prioritize client safety by immediately reporting these alarming findings to the registered nurse so that timely medical intervention can be initiated.

Step-by-Step Solution

1
Compare the client's current vital signs to their pre-procedure baseline.
Blood pressure has dropped significantly from 138/76 to 102/58 mmHg, and heart rate has increased from 72 to 108 beats/min.
To identify early hemodynamic instability indicative of hypovolemia or shock.
2
Correlate the vital sign changes with the client's reported symptom of new lower right back pain.
The combination of back pain, hypotension, and tachycardia suggests retroperitoneal bleeding, a known and severe complication of femoral artery access.
Back or flank pain following a femoral catheterization is a classic clinical indicator of internal retroperitoneal hemorrhage.
3
Determine the appropriate action based on the PN scope of practice.
The PN must notify the registered nurse (RN) immediately rather than independently managing the complication.
The client is experiencing a potentially life-threatening complication that requires RN-level assessment, clinical judgment, and immediate provider notification.

Key Concept

Recognizing Complications of Diagnostic Procedures
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Topics

Reduction of Risk Potential

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