Examkin

Question

Difficulty: EasyReduction of Risk Potential

A 70-year-old client is recovering in the telemetry unit 3 hours after a percutaneous transluminal coronary angioplasty (PTCA) utilizing the right femoral artery approach. The client suddenly reports severe lower back pain and generalized weakness. The nurse observes that the client's blood pressure is 84/50 mm Hg and heart rate is 118 beats per minute. A stat arterial blood gas (ABG) reveals a pH of 7.30, PaCO2 of 36 mm Hg, and HCO3 of 16 mEq/L. Which action must the nurse take immediately to mitigate the risk of further physiological decompensation?

  1. A
    Assist the client into a high-Fowler's position to determine if the lower back pain is relieved by sitting upright.
  2. Notify the healthcare provider immediately and prepare to administer rapid intravenous fluid resuscitation.Answer
  3. C
    Document the arterial blood gas results as a normal, expected respiratory response to post-procedural anxiety.
  4. D
    Perform a comprehensive neurological examination before assessing the right femoral insertion site.

Answer

Notify the healthcare provider immediately and prepare to administer rapid intravenous fluid resuscitation.
The client's presentation of sudden lower back pain, hypotension, and tachycardia shortly after a femoral artery procedure is a classic clinical picture of a retroperitoneal hemorrhage. The accompanying arterial blood gas results demonstrate metabolic acidosis, which occurs secondary to poor tissue perfusion and lactic acid buildup during hypovolemic shock. Immediate provider notification and rapid fluid volume replacement are essential to stabilize the client and prevent life-threatening cardiovascular collapse.

Step-by-Step Solution

1
Analyze the client's presenting symptoms and vital signs.
The client exhibits severe lower back pain, hypotension (84/50 mm Hg), and tachycardia (118 beats per minute).
These are hallmark indicators of retroperitoneal bleeding, a severe complication of femoral artery access that quickly leads to hypovolemic shock.
2
Interpret the arterial blood gas (ABG) values.
The ABG demonstrates a pH of 7.30 (acidemia), PaCO2 of 36 mm Hg (normal), and HCO3 of 16 mEq/L (low).
These values confirm uncompensated metabolic acidosis, which occurs when poor tissue perfusion from shock causes lactic acid accumulation in the bloodstream.
3
Determine the priority risk reduction intervention.
The nurse must immediately notify the healthcare provider and prepare for rapid intravenous fluid administration.
Restoring intravascular volume is the critical first step to stabilize the client's hemodynamic status and prevent cardiovascular collapse.

Key Concept

Identifying and managing retroperitoneal hemorrhage and hypovolemic shock following femoral artery catheterization.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic