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Zorluk: Çok zorReduction of Risk Potential

While performing a postoperative assessment, a licensed practical nurse (LPN) evaluates a client who underwent a percutaneous coronary intervention via the right femoral artery 4 hours ago. The client reports a new, continuous dull ache in the lower back. Inspection of the right groin reveals a dry surgical dressing with no localized swelling. Bilateral pedal pulses are palpable and symmetric. The client's baseline vital signs were blood pressure 144/82 mm Hg and heart rate 70 bpm. Current vital signs are blood pressure 104/62 mm Hg, heart rate 116 bpm, and respirations 20/min. Based on these findings, which action should the LPN take first?

  1. Immediately notify the registered nurse of the vital sign trends and the client's back pain.Cevap
  2. B
    Reassess the client's vital signs in one hour since the insertion site exhibits no visible bleeding.
  3. C
    Administer the prescribed as-needed (PRN) acetaminophen and apply a warm compress to the lower back.
  4. D
    Elevate the head of the bed to a 60-degree angle to reduce strain on the client's lower back muscles.

Cevap

The LPN should immediately notify the registered nurse of the vital sign trends and the client's back pain.
The correct action is to immediately notify the registered nurse. After a femoral artery procedure, blood can leak internally into the retroperitoneal space. Because the bleeding is internal, the external groin dressing often remains dry and intact. The classic presentation of a retroperitoneal hemorrhage includes new-onset lower back or flank pain, accompanied by hemodynamic instability (tachycardia and hypotension). The LPN must recognize these subtle shock signs and escalate care immediately to prevent severe hypovolemia.

Adım Adım Çözüm

1
Analyze the client's procedure and current symptoms.
The client had a right femoral artery puncture and is now experiencing new-onset lower back pain.
Back or flank pain after a femoral catheterization is a primary indicator of retroperitoneal bleeding, where blood pools in the retroperitoneal cavity rather than at the visible groin site.
2
Evaluate the vital sign trends against the baseline.
Blood pressure has dropped significantly (144/82 to 104/62) and heart rate has increased (70 to 116).
Tachycardia and hypotension are compensatory mechanisms indicating early hypovolemic shock due to internal blood loss.
3
Determine the priority nursing intervention within the LPN scope of practice.
The LPN must escalate these findings to the RN immediately.
A retroperitoneal hemorrhage is a life-threatening complication that requires rapid fluid resuscitation, potential blood transfusions, and possible surgical intervention, all of which require RN and provider collaboration.

Anahtar Kavram

Recognizing early signs of retroperitoneal hemorrhage (internal bleeding) following a femoral artery procedure.
Tahmini Süre:1m 30s
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Reduction of Risk Potential

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