A nurse is caring for a -year-old client who returned to the telemetry unit hours ago following a percutaneous coronary intervention (PCI) via the right femoral artery. Which of the following assessment findings require immediate follow-up by the nurse? Select all that apply.
- The client reports a new onset of dull, aching pain in the right flank and lower back.Answer
- The client's heart rate steadily increases from to beats per minute over a -minute period.Answer
- The client's right foot is pale and feels cooler to the touch compared to the left foot.Answer
- DThe client is positioned supine with the head of the bed elevated degrees and the affected leg kept straight.
- ERecent arterial blood gas results reveal a of , of , and of .
- FThe client's right dorsalis pedis pulse is palpated as , which is unchanged from the pre-procedure baseline assessment.
Answer
The findings that require immediate follow-up are the new onset of dull right flank/lower back pain, the steadily increasing heart rate, and the pale, cool right foot.
Following a femoral cardiac catheterization, the nurse must monitor closely for acute complications. Dull, aching pain in the flank or lower back is a classic symptom of a retroperitoneal hemorrhage. A steadily increasing heart rate is an early systemic sign of hypovolemic shock due to internal bleeding. A pale and cool extremity distal to the puncture site indicates arterial occlusion or thrombosis, which compromises tissue perfusion. All of these findings signal severe complications requiring immediate emergency intervention.
Step-by-Step Solution
Key Concept
Reduction of Risk Potential: Post-Procedure Complication Monitoring