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Difficulty: MediumReduction of Risk Potential

A nurse is caring for a client who underwent a right transfemoral cardiac catheterization two hours ago. The client reports a new onset of dull, aching pain in the lower right back. Which of the following actions should the nurse take first?

  1. A
    Elevate the head of the bed to forty-five degrees to reduce strain on the lower back.
  2. Assess the right femoral insertion site and bilateral pedal pulses.Answer
  3. C
    Administer the prescribed PRN oral analgesic for musculoskeletal pain relief.
  4. D
    Assist the client into a left side-lying position to promote comfort.

Answer

The correct action is to assess the right femoral insertion site and bilateral pedal pulses.
Back or flank pain following a transfemoral cardiac catheterization is a classic early symptom of retroperitoneal bleeding. Because this is a life-threatening complication, the nurse must immediately assess the insertion site for hematoma and check distal pulses to evaluate perfusion before initiating any other intervention.

Step-by-Step Solution

1
Analyze the client's history and current symptoms.
The client had a right transfemoral cardiac catheterization two hours ago and is now experiencing new-onset lower back pain.
Identifying the timing and nature of the symptom helps pinpoint potential post-procedure complications.
2
Correlate the symptom with known complications of the procedure.
Lower back or flank pain following this procedure is a hallmark sign of retroperitoneal bleeding, a severe complication of femoral arterial puncture.
Blood tracking into the retroperitoneal space causes pressure and referred pain to the lower back.
3
Determine the priority nursing intervention based on the nursing process.
The nurse must directly assess the femoral insertion site for swelling or hematoma and check distal pulses to confirm the presence of bleeding before taking any other action.
Assessment must always precede intervention, especially when anticipating impending shock from a massive internal bleed.

Key Concept

Monitoring for and responding to post-procedure complications, specifically retroperitoneal bleeding after a transfemoral cardiac catheterization.
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Reduction of Risk Potential

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