Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A client is resting in bed 3 hours after a cardiac catheterization performed via the right femoral artery. The client presses the call light and reports a new, constant dull ache in the lower back. The practical nurse (PN) obtains the following vital signs: blood pressure 100/62 mm Hg, heart rate 108 beats/min, and respiratory rate 18 breaths/min. Which of the following is the priority action for the PN?

  1. A
    Administer the prescribed PRN acetaminophen for pain relief
  2. B
    Elevate the head of the bed to 45 degrees to reduce back strain
  3. Notify the registered nurse (RN) immediatelyCevap
  4. D
    Document the findings and reassess vital signs in 30 minutes

Cevap

Notify the registered nurse (RN) immediately.
The correct answer addresses a critical, life-threatening complication. Following a cardiac catheterization via the femoral artery, blood can leak from the puncture site into the retroperitoneal space. Because this space can hold a large volume of blood before outward signs appear, the classic presentation is new-onset back or flank pain combined with subtle signs of hypovolemic shock, such as tachycardia (heart rate of 108) and dropping blood pressure. The PN must recognize these signs as an emergency and immediately notify the RN to facilitate rapid interventions like IV fluid resuscitation and a CT scan.

Adım Adım Çözüm

1
Analyze the client's new symptoms and vital signs in the context of the recent invasive procedure.
The client has new lower back pain, tachycardia (HR 108), and a borderline low blood pressure (100/62) following a right femoral artery puncture.
Recognizing patterns of complications after specific procedures is essential for early identification of life-threatening events.
2
Correlate the findings with potential post-procedure complications.
Bleeding from a femoral arterial puncture can track backward into the retroperitoneal space, causing flank or lower back pain and systemic signs of hypovolemia.
Retroperitoneal hemorrhage is a known, severe complication of femoral cardiac catheterization.
3
Determine the priority nursing action within the PN scope of practice.
The priority is to immediately notify the RN or healthcare provider to initiate rapid medical intervention.
Internal hemorrhage leading to shock requires urgent collaborative management beyond the scope of independent PN practice.

Anahtar Kavram

Recognizing and Escalating Complications of Invasive Procedures
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru