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Difficulty: MediumReduction of Risk Potential

A nurse is evaluating a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. Which of the following assessment findings require immediate intervention? Select all that apply.

  1. The client reports a new, sudden onset of right-sided flank pain.Answer
  2. The client's heart rate has increased steadily from 78 to 112 beats per minute over the last hour.Answer
  3. The client is resting in bed with the head of the bed elevated to a 60-degree angle.Answer
  4. D
    The client's current blood pressure is 118/76 mm Hg, compared to a pre-procedure baseline of 124/80 mm Hg.
  5. E
    The client's most recent arterial blood gas analysis reveals a pH of 7.42, PaCO2 of 38 mm Hg, and HCO3 of 24 mEq/L.
  6. F
    The client's right pedal pulse is palpable and equal in amplitude to the left pedal pulse.

Answer

The findings requiring immediate intervention include the new onset of right-sided flank pain, a steadily increasing heart rate, and the head of the bed being elevated to a 60-degree angle.
The correct options identify significant risks and complications associated with femoral artery access. Sudden flank pain is a classic indicator of retroperitoneal hemorrhage. A steadily increasing heart rate is an early compensatory sign of hypovolemic shock. Elevating the head of the bed to 60 degrees is a contraindicated position because severe hip flexion can dislodge the clot at the femoral insertion site, leading to acute bleeding.

Step-by-Step Solution

1
Analyze the procedure and approach.
The client underwent a percutaneous coronary intervention via the right femoral artery.
Identifying the procedure highlights the specific risks: femoral access carries a high risk of bleeding, hematoma, retroperitoneal hemorrhage, and arterial occlusion.
2
Evaluate each option for signs of complications or procedural risks.
Flank pain indicates internal bleeding. Tachycardia indicates early shock. A bed elevated to 60 degrees creates hip flexion that risks dislodging the clot.
Differentiating between expected post-procedure findings and actual physiological decompensation is essential for risk reduction.
3
Differentiate abnormal findings from normal post-procedure data.
Slightly lower blood pressure, normal ABG values, and palpable pedal pulses are normal, expected findings that do not require intervention.
Recognizing normal parameters prevents unnecessary interventions and improper prioritization.

Key Concept

Post-Cardiac Catheterization Complication Monitoring
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Topics

Reduction of Risk Potential

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