Following a diagnostic cardiac catheterization via the right femoral artery, a client is recovering on the telemetry unit. Later in the shift, the client activates the call light and complains of a new, constant, dull ache in the lower back. The practical nurse assesses the client and compares current vital signs with previous documentation:
| Time | Blood Pressure | Heart Rate | Respiratory Rate |
|---|---|---|---|
| 12:00 | 138/84 mm Hg | 72/min | 16/min |
| 14:00 | 126/78 mm Hg | 86/min | 18/min |
| 16:00 | 104/62 mm Hg | 110/min | 22/min |
Which action should the practical nurse take first?
- Inspect the right groin insertion site and posterior flank for swelling or ecchymosisCevap
- BProvide the prescribed as-needed acetaminophen to alleviate the client's back discomfort
- CExplain that a lumbar ache is an expected occurrence due to the required prolonged supine bed rest
- DElevate the head of the bed to a 45-degree angle to facilitate easier respiratory effort
Cevap
The priority action is to immediately inspect the right groin insertion site and posterior flank for signs of swelling or ecchymosis, which indicate internal bleeding.
The client's deteriorating vital signs (hypotension, narrowing pulse pressure, and tachycardia) combined with new-onset lower back pain after a femoral artery procedure are classic indicators of a retroperitoneal hemorrhage. Blood tracking backward into the retroperitoneal space causes back or flank pain. The practical nurse must immediately inspect the insertion site and flank for physical evidence of a hematoma or ecchymosis to confirm the suspicion of internal bleeding. This critical data must then be rapidly communicated to the registered nurse for emergency intervention.
Adım Adım Çözüm
Anahtar Kavram
Early recognition of hemorrhagic shock and retroperitoneal bleeding
Tahmini Süre:2m 0s