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Difficulty: HardReduction of Risk Potential

A nurse is evaluating an adult client who returned to the cardiac step-down unit 45 minutes45\text{ minutes} ago following a percutaneous coronary intervention (PCI) via the right femoral artery. The client's baseline vital signs prior to the procedure were: blood pressure 138/82 mm Hg138/82\text{ mm Hg}, heart rate 72 beats per minute72\text{ beats per minute}, and respiratory rate 16 breaths per minute16\text{ breaths per minute}. Which of the following assessment findings require immediate intervention by the nurse to reduce the risk of physiological decompensation? (Select all that apply.)

  1. The client is resting with the head of the bed elevated to a 60∘60^\circ angle.Answer
  2. The client reports a new, persistent dull ache in the right flank and lower back.Answer
  3. The client's current vital signs are blood pressure 102/58 mm Hg102/58\text{ mm Hg} and heart rate 116 beats per minute116\text{ beats per minute}.Answer
  4. D
    Arterial blood gas values display a pH\text{pH} of 7.387.38, PaCO2\text{PaCO}_2 of 42 mm Hg42\text{ mm Hg}, and HCO3−\text{HCO}_3^- of 24 mEq/L24\text{ mEq/L}.
  5. E
    A 2 cm2\text{ cm} area of dry, dark red blood is visible on the pressure dressing with no signs of expansion.
  6. F
    The right dorsalis pedis pulse is +2+2, and the right lower extremity is warm and matches the left.

Answer

The findings requiring immediate intervention are the head of the bed elevated to 60 degrees, the new flank and lower back pain, and the vital signs showing hypotension with tachycardia.
The correct options represent critical safety breaches or signs of life-threatening post-procedure complications. Elevating the head of the bed beyond 30 degrees places excessive tension on the femoral puncture site, severely increasing the risk of hemorrhage. A new dull ache in the flank or lower back is a hallmark sign of a retroperitoneal hemorrhage, a hidden and potentially fatal bleed. The significant drop in blood pressure accompanied by tachycardia indicates early hemorrhagic shock, requiring rapid medical response.

Step-by-Step Solution

1
Analyze the client's clinical presentation and procedure history.
The client had a PCI via the right femoral artery 45 minutes ago, putting them at high risk for access-site bleeding, retroperitoneal hemorrhage, and arterial occlusion.
Identifying the specific procedure determines the targeted post-operative complications to monitor.
2
Evaluate the assessment findings for signs of hemorrhage or shock.
The new flank pain indicates a potential retroperitoneal bleed. The vital sign changes (hypotension and tachycardia) confirm impending hemorrhagic shock.
Early recognition of internal bleeding is critical to prevent fatal physiological decompensation.
3
Assess environmental and positional safety factors.
The client is sitting at a 60-degree angle, which is contraindicated.
The head of the bed must remain flat or elevated no more than 30 degrees to prevent tension and rupture of the femoral access site.
4
Differentiate between normal and abnormal diagnostic or physical findings.
The ABG values, small amount of dry blood, and strong bilateral pulses are all normal, expected findings.
Accurate clinical judgment requires prioritizing interventions only for pathological or high-risk findings.

Key Concept

Reduction of Risk Potential: Post-catheterization complications and hemodynamics
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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