A client is recovering on the telemetry unit four hours after a percutaneous coronary intervention performed through the right femoral artery. When the practical nurse enters the room, the client complains of a new, persistent dull ache in the lower back and right flank. Current vital signs include a heart rate of 106 beats/min and a blood pressure of 104/64 mm Hg, compared to a pre-procedure baseline of 78 beats/min and 126/78 mm Hg. The femoral insertion site dressing remains clean, dry, and intact. Which action should the nurse take first?
- Escalate the findings immediately to the registered nurse due to the risk of internal hemorrhage.Cevap
- BAdminister the prescribed as-needed analgesic to relieve the client's reported back discomfort.
- CDocument the findings and continue routine hourly monitoring since the insertion site is free of bleeding.
- DAssist the client into a side-lying position to decrease pressure and tension on the lumbar spine.
Cevap
The correct action is to escalate the findings immediately to the registered nurse due to the risk of internal hemorrhage.
The correct answer identifies the need for immediate escalation. A client who has undergone a femoral cardiac catheterization is at high risk for a retroperitoneal hemorrhage. Because the bleeding occurs internally into the retroperitoneal space, the external femoral dressing will often appear dry and intact. The classic signs of this severe complication are new-onset lower back or flank pain, accompanied by early signs of hypovolemic shock, such as an increasing heart rate and a decreasing blood pressure. The practical nurse must recognize this acute physiological deterioration and immediately escalate the findings to the registered nurse or provider for rapid intervention.
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Recognition of Retroperitoneal Hemorrhage