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Zorluk: OrtaReduction of Risk Potential

A client is resting in bed on the telemetry unit 4 hours after a diagnostic cardiac catheterization performed via the right femoral artery. During routine data collection, the client complains of a new, persistent ache in the lower back. Current vital signs show a blood pressure of 102/64 mm Hg and a pulse of 112 beats per minute, compared to a pre-procedure baseline of 134/78 mm Hg and 76 beats per minute. Which action should the practical nurse (PN) take first?

  1. A
    Administer the prescribed as-needed analgesic for the back ache.
  2. B
    Help the client roll onto the left side to alleviate pressure on the lower back.
  3. C
    Document the vital signs in the electronic health record and reassess in 30 minutes.
  4. Notify the registered nurse (RN) immediately about the assessment findings.Cevap

Cevap

Notify the registered nurse (RN) immediately about the assessment findings.
Following a femoral cardiac catheterization, the onset of new lower back pain combined with tachycardia and a dropping blood pressure are hallmark indicators of retroperitoneal hemorrhage. This is a critical circulatory emergency. Within the practical nurse scope of practice, recognizing these signs of hypovolemic shock necessitates immediate escalation to the registered nurse (RN) or healthcare provider for rapid medical intervention.

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1
Analyze the client's post-procedure symptoms and vital sign trends.
The client has new lower back pain, hypotension, and tachycardia compared to baseline.
Identifying deviations from baseline is critical for recognizing early postoperative complications.
2
Correlate the findings with potential complications of a femoral arterial puncture.
These combined findings strongly suggest retroperitoneal bleeding, a severe circulatory compromise.
Blood leaking backward into the retroperitoneal space causes back pain and subsequent hypovolemia.
3
Determine the priority nursing intervention within the PN scope of practice.
The PN must immediately escalate these critical, unstable findings to the RN.
Life-threatening emergencies require rapid RN or provider intervention for fluid resuscitation and medical management.

Anahtar Kavram

Recognizing early signs of hemorrhage and hypovolemic shock post-procedure
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Konular

Reduction of Risk Potential

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