Examkin

Question

Difficulty: MediumReduction of Risk Potential

Following a percutaneous coronary intervention (PCI) via the right femoral artery, a client is transferred to the cardiac step-down unit. Two hours later, the client reports new-onset, severe right flank pain. Baseline vital signs upon arrival were a blood pressure of 132/76 mm Hg and a heart rate of 74 bpm. Current vital signs reveal a blood pressure of 96/52 mm Hg and a heart rate of 118 bpm. Assessment of the femoral access site shows a dry, intact dressing with no visible hematoma, and pedal pulses remain palpable bilaterally. Based on these findings, which of the following is the priority action?

  1. Notify the healthcare provider and anticipate administering rapid intravenous fluids.Answer
  2. B
    Administer the prescribed as-needed opioid analgesic for the flank pain.
  3. C
    Elevate the head of the bed to 45 degrees to relieve pressure on the lower back.
  4. D
    Apply continuous manual pressure directly over the superficial femoral insertion site.

Answer

The correct action is to notify the healthcare provider and anticipate administering rapid intravenous fluids.
The client is exhibiting classic signs of a retroperitoneal hemorrhage, a critical complication of a femoral percutaneous coronary intervention (PCI). Blood pooling in the retroperitoneal space causes severe flank or lower back pain, while the significant drop in blood pressure and compensatory tachycardia are clear indicators of hemorrhagic shock. Because this bleeding tracks internally into the retroperitoneal cavity, the superficial skin dressing will often remain completely dry and intact. The priority action is to immediately notify the healthcare provider or rapid response team and prepare for fluid resuscitation to restore intravascular volume.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends.
The client has new-onset flank pain, a significant drop in blood pressure (from 132/76 to 96/52 mm Hg), and an increased heart rate (from 74 to 118 bpm).
Recognizing deviations from baseline vital signs is crucial for early detection of complications.
2
Correlate the findings with the recent femoral artery procedure.
The combination of flank pain and signs of hypovolemic shock, despite a dry superficial dressing, strongly indicates a retroperitoneal hemorrhage.
Blood leaking from the arterial puncture site can track backward into the retroperitoneal space, remaining invisible on the surface while causing severe pain and shock.
3
Determine the priority nursing intervention.
The immediate priority is to notify the healthcare provider and prepare to restore intravascular volume with intravenous fluids.
Hemorrhagic shock is a life-threatening emergency that requires prompt medical escalation and volume replacement.

Key Concept

Recognizing and managing retroperitoneal hemorrhage as a complication of femoral artery procedures.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic