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Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is caring for a client who returned 2 hours ago from a diagnostic cardiac catheterization performed via the right femoral artery. The client's pre-procedure vital signs were a blood pressure of 138/76 mmHg and a heart rate of 72 beats/min. The client now reports a new onset of dull, aching pain in the lower right back. Current vital signs are blood pressure 102/58 mmHg, heart rate 108 beats/min, and respiratory rate 18 breaths/min. Which of the following actions is the priority for the PN to take?

  1. Immediately report the assessment findings to the registered nurse.Cevap
  2. B
    Document the vital signs and continue to monitor the client every 15 minutes.
  3. C
    Assist the client into a high-Fowler's position to alleviate the back discomfort.
  4. D
    Perform a comprehensive physical assessment to determine the source of the back pain.

Cevap

Immediately report the assessment findings to the registered nurse.
The client's new-onset tachycardia, relative hypotension, and lower back pain strongly indicate retroperitoneal bleeding, a severe and potentially life-threatening complication of a femoral cardiac catheterization. The practical nurse must prioritize client safety by immediately reporting these alarming findings to the registered nurse so that timely medical intervention can be initiated.

Adım Adım Çözüm

1
Compare the client's current vital signs to their pre-procedure baseline.
Blood pressure has dropped significantly from 138/76 to 102/58 mmHg, and heart rate has increased from 72 to 108 beats/min.
To identify early hemodynamic instability indicative of hypovolemia or shock.
2
Correlate the vital sign changes with the client's reported symptom of new lower right back pain.
The combination of back pain, hypotension, and tachycardia suggests retroperitoneal bleeding, a known and severe complication of femoral artery access.
Back or flank pain following a femoral catheterization is a classic clinical indicator of internal retroperitoneal hemorrhage.
3
Determine the appropriate action based on the PN scope of practice.
The PN must notify the registered nurse (RN) immediately rather than independently managing the complication.
The client is experiencing a potentially life-threatening complication that requires RN-level assessment, clinical judgment, and immediate provider notification.

Anahtar Kavram

Recognizing Complications of Diagnostic Procedures
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Konular

Reduction of Risk Potential

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