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Difficulty: MediumReduction of Risk Potential

A nurse is caring for a client who is 44 hours post-cardiac catheterization via the right femoral artery. The client begins reporting new, severe discomfort in the lower back and flank area, along with mild dizziness. Current vital signs reveal a blood pressure of 96/5496/54 mm Hg and a heart rate of 114114 beats per minute. The femoral insertion site dressing is completely dry and intact. Which action should the nurse take first to address the client's risk of physiological decompensation?

  1. A
    Elevate the head of the bed to 4545 degrees to relieve the pressure on the client's lower back.
  2. B
    Document the symptoms as expected muscle stiffness from prolonged bed rest and monitor closely.
  3. Keep the client in a flat, supine position and immediately notify the healthcare provider.Answer
  4. D
    Request an immediate 1212-lead electrocardiogram to evaluate for procedure-related cardiac ischemia.

Answer

The correct action is to keep the client in a flat, supine position and immediately notify the healthcare provider.
The client's presentation of severe back pain, hypotension, and tachycardia after a femoral artery procedure strongly indicates retroperitoneal bleeding. Because the blood is pooling internally, the external dressing remains clean and dry. The nurse must keep the client flat to avoid bending the groin, which could exacerbate the arterial bleed, and must immediately notify the provider to initiate emergency volume resuscitation and diagnostics.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent procedure.
The client had a right femoral artery puncture 44 hours ago and is now experiencing severe back/flank pain, hypotension (96/5496/54 mm Hg), and tachycardia (114114 bpm).
Identifying the relationship between the invasive procedure and the sudden change in vital signs is necessary to determine the underlying complication.
2
Correlate the symptoms with potential post-catheterization complications.
The combination of back pain, dropping blood pressure, and rising heart rate with a dry groin dressing points to internal retroperitoneal bleeding.
Blood from a femoral arterial leak can pool backward into the retroperitoneal space, hiding external signs of hemorrhage while producing signs of hypovolemic shock and referred back pain.
3
Select the nursing intervention that mitigates the immediate physiological risk.
The nurse must ensure the client remains flat to prevent bending at the groin and alert the provider to manage the hemorrhage.
Immediate medical intervention (such as fluid resuscitation or surgical repair) is required to prevent cardiovascular collapse, and positioning protects the clot.

Key Concept

Recognizing and mitigating the risk of retroperitoneal hemorrhage following femoral artery access.
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Topics

Reduction of Risk Potential

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