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Question

Difficulty: HardEstablishing Priorities

Upon receiving the handoff report on a cardiovascular step-down unit, the nurse is planning the initial client rounds. Which client requires the nurse's immediate assessment?

  1. A client who underwent a percutaneous coronary intervention via the right femoral artery 4 hours ago and is reporting a new onset of continuous lower back pain.Answer
  2. B
    A client admitted with infective endocarditis who is receiving a scheduled intravenous antibiotic infusion and has a current temperature of 101.5°F (38.6°C).
  3. C
    A client with chronic heart failure who exhibits bilateral 2+ pitting lower extremity edema and has a morning brain natriuretic peptide (BNP) level of 850 pg/mL.
  4. D
    A client who had a permanent pacemaker implanted 48 hours ago and is experiencing occasional, isolated premature ventricular contractions on the telemetry monitor.

Answer

The client reporting a new onset of continuous lower back pain after a femoral percutaneous coronary intervention requires immediate assessment due to the risk of retroperitoneal hemorrhage.
The correct answer is the client reporting lower back pain after a femoral percutaneous coronary intervention. Back or flank pain following a femoral arterial puncture is a primary indicator of retroperitoneal hemorrhage. This internally sequestered bleeding can rapidly lead to hemorrhagic shock if not immediately identified and managed. Because it is a direct threat to circulation, this client is the highest priority.

Step-by-Step Solution

1
Analyze the clinical presentation of the post-percutaneous coronary intervention (PCI) client.
Recognize that new-onset lower back pain after a femoral arterial puncture indicates a potential retroperitoneal hemorrhage, which is an acute, life-threatening circulatory complication.
Identifying acute, unstable complications is the first step in prioritization using the Airway-Breathing-Circulation (ABC) framework.
2
Evaluate the remaining clients' clinical presentations for acuity.
Identify that a fever in endocarditis, an elevated BNP with edema in heart failure, and isolated PVCs post-pacemaker insertion are all expected or stable chronic findings.
Distinguishing between expected disease manifestations and unexpected acute deterioration is necessary for accurate triage.
3
Compare the acuity and stability of all four clients to determine the assessment order.
Determine that the potential retroperitoneal hemorrhage poses the most immediate threat to the client's life and requires the first assessment.
The client with the most acute, unexpected, and life-threatening condition must be seen first according to priority frameworks.

Key Concept

Prioritization: Recognizing Acute vs. Expected Findings
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Topics

Establishing Priorities

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