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Difficulty: MediumReduction of Risk Potential

A 68-year-old client with a history of coronary artery disease and mild chronic obstructive pulmonary disease (COPD) is recovering on the telemetry unit 2 hours after a percutaneous coronary intervention (PCI) via the right femoral artery. The client's baseline vital signs upon admission were blood pressure 138/82 mm Hg and heart rate 72 beats/min. Which assessment finding requires the nurse to intervene immediately?

  1. The client's heart rate has steadily increased to 112 beats/min, and blood pressure is 114/78 mm Hg.Answer
  2. B
    The client reports mild stiffness in the lower back after maintaining a supine position with the head of the bed flat.
  3. C
    An arterial blood gas (ABG) drawn due to the client's COPD history shows a pH of 7.37, PaCO2 of 44 mm Hg, and HCO3- of 25 mEq/L.
  4. D
    The client reports a dull, aching pain rated as 2 on a 0 to 10 scale at the femoral catheter insertion site.

Answer

The client's heart rate has steadily increased to 112 beats/min, and blood pressure is 114/78 mm Hg.
Following a percutaneous coronary intervention via the femoral artery, the client is at high risk for retroperitoneal hemorrhage. A steadily increasing heart rate combined with a narrowing pulse pressure (from a baseline of 56 mm Hg down to 36 mm Hg) are classic, subtle indicators of early hypovolemic shock. Immediate intervention is required to manage the internal bleeding and prevent cardiovascular collapse.

Step-by-Step Solution

1
Analyze the client's recent procedure and identify potential high-risk complications associated with it.
The client underwent a PCI via the femoral artery, which carries a significant risk for arterial bleeding and retroperitoneal hemorrhage.
Understanding the specific risks of the procedure guides a focused clinical assessment.
2
Compare the client's current vital signs to their baseline to detect subtle physiological trends.
The heart rate increased significantly from 72 to 112 beats/min, and the pulse pressure narrowed from 56 mm Hg (138-82) to 36 mm Hg (114-78).
Early hypovolemic shock often presents as tachycardia and a narrowing pulse pressure before profound hypotension becomes evident.
3
Evaluate the remaining options to distinguish expected post-procedure findings from critical complications.
Back stiffness from lying flat, normal ABG values, and mild insertion site pain are expected or normal findings, whereas the vital sign changes indicate impending cardiovascular compromise.
Clinical prioritization requires identifying and acting on the most acute, life-threatening issue.

Key Concept

Early detection of hypovolemic shock secondary to retroperitoneal hemorrhage post-cardiac catheterization.
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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