Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

A practical nurse is caring for a client who had a cardiac catheterization through the right femoral artery 6 hours ago. The client reports a new, continuous lower backache. During data collection, the nurse notes the right pedal pulse is palpable but weaker than the left, a heart rate of 104 beats per minute, and a blood pressure of 102/60 mm Hg. What is the priority action for the practical nurse?

  1. Alert the registered nurse immediately about the client's changing condition.Cevap
  2. B
    Document the vital signs and continue scheduled monitoring.
  3. C
    Provide the prescribed oral pain medication to manage the back discomfort.
  4. D
    Assist the client in turning to a side-lying position to reduce back pressure.

Cevap

The correct action is to alert the registered nurse immediately about the client's changing condition.
The client is exhibiting classic signs of retroperitoneal bleeding, a severe complication of a femoral artery cardiac catheterization. The new onset of continuous backache occurs because blood is accumulating in the retroperitoneal space, causing pressure. The diminished distal pulse and borderline vital signs (tachycardia and mild hypotension) indicate early hemorrhagic shock. The practical nurse must immediately escalate this critical circulatory emergency to the registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's procedure and current symptoms.
The client had a right femoral cardiac catheterization and now presents with new back pain, a weaker distal pulse, and borderline tachycardia and hypotension.
Identifying the combination of symptoms following this specific invasive procedure is crucial for recognizing early complications.
2
Correlate the clinical findings with potential postoperative complications.
These findings strongly indicate retroperitoneal bleeding.
Blood pooling in the retroperitoneal space causes referred back pain, while active volume loss leads to a compensatory increase in heart rate and a drop in blood pressure.
3
Determine the priority nursing action based on the practical nurse scope of practice.
The nurse must immediately escalate the findings to the registered nurse or provider.
A retroperitoneal hemorrhage is a critical circulatory emergency that requires immediate medical intervention and fluid resuscitation beyond the independent scope of a practical nurse.

Anahtar Kavram

Recognition of retroperitoneal bleeding following femoral artery procedures
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru