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Difficulty: MediumPhysiological Adaptation

A nurse is conducting a follow-up assessment on a client who underwent a transfemoral cardiac catheterization two hours ago. The client is resting in a supine position and reports the new onset of mild back pain. Which of the following vital sign profiles requires the nurse to activate the rapid response team?

  1. A
    Blood pressure 98/62 mm Hg, heart rate 74 beats/minute, respiratory rate 16 breaths/minute
  2. Blood pressure 110/88 mm Hg, heart rate 108 beats/minute, respiratory rate 22 breaths/minuteAnswer
  3. C
    Blood pressure 142/84 mm Hg, heart rate 68 beats/minute, respiratory rate 14 breaths/minute
  4. D
    Blood pressure 128/72 mm Hg, heart rate 82 beats/minute, respiratory rate 24 breaths/minute

Answer

The vital sign profile demonstrating a blood pressure of 110/88 mm Hg, a heart rate of 108 beats/minute, and a respiratory rate of 22 breaths/minute indicates a medical emergency.
The correct answer indicates a narrowing pulse pressure of 2222 mm Hg combined with tachycardia and mild tachypnea. In a client who recently underwent a transfemoral cardiac catheterization, the new onset of back pain is a classic indicator of a retroperitoneal hemorrhage. These vital signs reflect the body's compensatory mechanisms for acute hypovolemia, prioritizing immediate emergency intervention.

Step-by-Step Solution

1
Analyze the clinical scenario and associated risks.
Identify that a transfemoral cardiac catheterization carries a high risk for bleeding, and new-onset back pain strongly suggests a retroperitoneal hemorrhage.
Anticipating potential procedural complications directs the focus of the vital sign assessment.
2
Evaluate the principles of compensatory shock.
Recall that early hypovolemic shock presents with a narrowing pulse pressure (systolic minus diastolic) and an increasing heart rate.
This determines which vital sign profile reflects acute physiological deterioration before profound hypotension occurs.
3
Calculate and compare parameters across the options.
Assess the correct profile: the pulse pressure is 2222 mm Hg (110−88110 - 88), which is significantly narrowed, and the heart rate is elevated at 108 beats/minute.
This confirms the presence of compensatory shock, making it the highest priority for emergency intervention.

Key Concept

Early recognition of hypovolemic shock and retroperitoneal bleeding
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Topics

Physiological Adaptation

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