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Difficulty: MediumReduction of Risk Potential

A nurse is evaluating a client who returned to the nursing unit 22 hours ago following a cardiac catheterization via the right radial artery approach. Which of the following assessment findings should the nurse identify as the highest priority to report to the healthcare provider?

  1. A
    A client report of throbbing pain rated as a 33 on a 00 to 1010 scale at the right wrist.
  2. B
    A client position with the head of the bed elevated to a 4545-degree angle.
  3. Right fingers that appear pale and feel cooler to the touch compared to the left fingers.Answer
  4. D
    An arterial blood gas (ABG) analysis result showing a pH of 7.417.41, PaCO2\text{PaCO}_2 of 4040 mmHg, and PaO2\text{PaO}_2 of 9494 mmHg.

Answer

Right fingers that appear pale and feel cooler to the touch compared to the left fingers.
Following a radial artery cardiac catheterization, the most significant risk is compromised perfusion to the hand due to arterial spasm, thrombosis, or hematoma. Pallor and coolness in the extremity distal to the puncture site are classic, early indicators of arterial occlusion. This is a limb-threatening medical emergency that requires immediate notification of the healthcare provider to restore perfusion.

Step-by-Step Solution

1
Identify the anatomical approach and specific risks of the procedure.
The procedure utilized a right radial artery approach. A major physiological risk is arterial occlusion or hematoma at the wrist, which can compromise arterial perfusion to the hand.
Understanding the specific access site directs the nurse to perform a focused neurovascular assessment on the correct extremity.
2
Evaluate the clinical significance of each assessment finding presented.
Mild wrist pain is expected. Sitting at a 4545-degree angle is safe for a radial approach. The ABG results are completely normal. However, pale and cool fingers indicate impaired blood flow.
Discriminating between expected post-operative findings, normal diagnostic results, and pathological changes prevents delayed emergency care.
3
Determine the priority finding that requires immediate provider intervention.
The signs of arterial occlusion (pallor, coolness) take immediate priority to prevent permanent tissue damage or limb loss.
Life- or limb-threatening complications must always be prioritized over stable, expected, or easily manageable assessment data.

Key Concept

Following a radial artery cardiac catheterization, the nurse must prioritize frequent neurovascular assessments (color, temperature, pulse, capillary refill) of the affected extremity to rapidly identify and intervene for arterial occlusion.
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Reduction of Risk Potential

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