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Difficulty: MediumPhysiological Adaptation

A nurse is caring for an adult client who is 4 hours post-percutaneous coronary intervention (PCI) via the right femoral artery. The client reports a new onset of dull, aching pain in the lower back. Current vital signs reveal a heart rate of 118 bpm, a blood pressure of 102/78 mmHg, and a respiratory rate of 22 breaths/min. The client's baseline vital signs upon arrival to the unit were a heart rate of 76 bpm and a blood pressure of 128/74 mmHg. Which of the following is the priority nursing action?

  1. A
    Elevate the head of the bed to 45 degrees to reduce strain on the lower back
  2. B
    Administer the prescribed PRN analgesic to relieve the client's back discomfort
  3. Assess the right femoral access site and flank area for swelling or ecchymosisAnswer
  4. D
    Request a prescription for a 12-lead electrocardiogram to evaluate the tachycardia

Answer

The priority nursing action is to assess the right femoral access site and flank area for swelling or ecchymosis.
The client's new onset of lower back pain, combined with tachycardia and a narrowing pulse pressure, strongly indicates a retroperitoneal hemorrhage—a severe complication of femoral artery access. The priority action is to apply the nursing process by first assessing the access site and the retroperitoneal/flank area to confirm the source of bleeding before taking further action.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends compared to the baseline.
The client has developed sudden tachycardia (76 to 118 bpm), hypotension with a narrowed pulse pressure (from 54 mmHg to 24 mmHg), and new-onset back pain.
Identifying changes from baseline is crucial for recognizing acute life-threatening complications.
2
Correlate the assessment findings with potential post-procedural complications.
The combination of back pain and signs of compensatory hypovolemic shock following a femoral artery puncture is the classic presentation of a retroperitoneal hemorrhage.
Blood leaking from the femoral artery can track backward into the retroperitoneal space, causing severe back or flank pain and hidden blood loss.
3
Determine the priority nursing action using the nursing process.
The nurse must first physically assess the access site and flank (checking for Grey Turner's sign or a hematoma) to confirm the bleeding source before intervening or notifying the provider.
Assessment must precede intervention to provide accurate, actionable data to the healthcare team.

Key Concept

Recognition and assessment of retroperitoneal hemorrhage following femoral artery access.
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Topics

Physiological Adaptation

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