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Difficulty: HardReduction of Risk Potential

An older adult client is recovering on the telemetry unit 2 hours after a cardiac catheterization performed via the right femoral artery approach. During rounding, the client reports the sudden onset of a dull, continuous ache in the lower right back. The insertion site dressing remains clean and dry with no visible hematoma. Current vital signs reveal a blood pressure of 102/58 mmHg and a heart rate of 108 bpm, compared to a baseline of 134/76 mmHg and 72 bpm upon arrival. Based on these findings, what is the priority action for the practical nurse?

  1. Immediately report the findings to the supervising registered nurse.Answer
  2. B
    Administer a prescribed as-needed mild analgesic to treat the back discomfort.
  3. C
    Raise the head of the bed to a 45-degree angle to relieve the back pressure.
  4. D
    Reassess the client's vital signs and back discomfort in 30 minutes.

Answer

Immediately report the findings to the supervising registered nurse.
The correct action is to immediately escalate the situation. Following a femoral cardiac catheterization, bleeding can occur internally into the retroperitoneal space. Because the blood pools backward, the external groin dressing will remain dry, but the client will experience back or flank pain as the blood irritates the tissues. The shifting vital signs (rising heart rate, falling blood pressure) are early indicators of hypovolemic shock. This is a medical emergency requiring immediate RN and provider intervention.

Step-by-Step Solution

1
Analyze the client's current symptoms and procedural history.
The client had a right femoral arterial puncture and is now experiencing new-onset lower right back pain.
Connecting post-procedural history to new symptoms is critical for identifying potential complications.
2
Evaluate the vital sign trends.
The heart rate has increased from 72 to 108 bpm, and the blood pressure has decreased from 134/76 to 102/58 mmHg.
Trending vital signs helps identify early physiological decline before overt shock occurs.
3
Synthesize the findings to identify the underlying risk.
The hidden nature of the bleeding (dry dressing) combined with back pain and borderline shock vitals strongly indicates a retroperitoneal hemorrhage.
Blood leaking from the posterior femoral artery tracks into the retroperitoneal space, causing back or flank pain without visible external bleeding.
4
Determine the appropriate practical nurse (PN) action.
The PN must immediately escalate the findings to the registered nurse (RN).
A retroperitoneal hemorrhage is a life-threatening emergency that requires advanced RN assessment, provider notification, and potential surgical or medical intervention beyond the PN scope.

Key Concept

Recognition and escalation of early shock and retroperitoneal bleeding following femoral arterial procedures.
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Topics

Reduction of Risk Potential

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