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Difficulty: HardPhysiological Adaptation

An adult client is recovering on the cardiac telemetry unit 3 hours after a percutaneous coronary intervention (PCI) via the right femoral artery. The client suddenly reports severe, continuous lower back pain. The nurse notes the client's blood pressure has dropped from a baseline of 134/76 mm Hg to 108/86 mm Hg, and the heart rate has increased from 78 to 114 beats/min. The femoral insertion site dressing remains dry and intact. Which of the following is the priority nursing action?

  1. A
    Reposition the client into a high Fowler's position to alleviate the lower back discomfort.
  2. B
    Administer the prescribed PRN intravenous opioid analgesic to manage the lower back pain.
  3. Contact the healthcare provider immediately and prepare to administer isotonic intravenous fluids.Answer
  4. D
    Apply firm, continuous manual pressure directly over the right femoral insertion site.

Answer

Contact the healthcare provider immediately and prepare to administer isotonic intravenous fluids.
The client's presentation of severe back pain, tachycardia, and a rapidly narrowing pulse pressure points directly to a retroperitoneal hemorrhage, which is a life-threatening complication of femoral artery access. The immediate priority is to notify the provider and prepare for systemic volume resuscitation to manage the impending hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's new onset symptoms and vital sign changes.
The client has sudden severe back pain, tachycardia, and a narrowing pulse pressure (dropping from 58 mm Hg to 22 mm Hg).
These are classic early indicators of retroperitoneal hemorrhage and impending hypovolemic shock following a femoral arterial puncture.
2
Evaluate the localized insertion site.
The femoral dressing is dry and intact.
This confirms the bleeding is not external, further supporting the suspicion of internal retroperitoneal bleeding into the flank or back.
3
Determine the priority nursing intervention.
The nurse must alert the medical team for immediate intervention while initiating volume resuscitation.
Internal hemorrhage cannot be managed with direct manual pressure; it requires immediate systemic hemodynamic support and potentially procedural or surgical intervention.

Key Concept

Early recognition and management of retroperitoneal hemorrhage and hypovolemic shock following femoral artery catheterization.
Estimated Time:1m 30s
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Physiological Adaptation

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