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Zorluk: ZorPhysiological Adaptation

A client is recovering on the telemetry unit 4 hours after a percutaneous coronary intervention (PCI) via the right femoral artery. The client reports a new, mild, dull ache in the lower back but denies chest pain or shortness of breath. The nurse notes the following vital sign trends over the past hour:

TimeBlood PressureHeart RateRespiratory Rate
14:00134/76 mm Hg74 bpm14 breaths/min
14:30128/82 mm Hg86 bpm16 breaths/min
15:00116/88 mm Hg104 bpm22 breaths/min

Which of the following actions should the nurse take FIRST?

  1. Inspect the right groin insertion site and gently logroll the client to assess the flank.Cevap
  2. B
    Administer the prescribed PRN analgesic for the lower back ache.
  3. C
    Initiate a rapid intravenous fluid bolus to treat the impending hypovolemia.
  4. D
    Obtain a 12-lead electrocardiogram to assess for post-procedural myocardial ischemia.

Cevap

Inspect the right groin insertion site and gently logroll the client to assess the flank.
The correct action is to assess the insertion site and flank. The vital sign trends (narrowing pulse pressure, tachycardia, tachypnea) combined with the new-onset lower back pain are classic signs of a retroperitoneal hemorrhage, a severe complication of femoral arterial access. The nursing process dictates that assessment must occur first to confirm the source of bleeding so immediate mechanical interventions (e.g., manual pressure) can be applied.

Adım Adım Çözüm

1
Analyze the client's symptoms and vital sign trends.
The client has a narrowing pulse pressure (58 to 28 mm Hg), increasing tachycardia, and tachypnea, along with new-onset lower back pain.
Recognizing early compensatory mechanisms of shock is essential for timely intervention.
2
Correlate the findings with the recent procedure (femoral PCI).
The clinical picture strongly suggests a retroperitoneal hemorrhage, a known complication of femoral arterial access.
Lower back or flank pain combined with hypovolemic signs post-femoral puncture is the classic presentation of retroperitoneal bleeding.
3
Determine the highest priority nursing action using the nursing process.
Assessment of the puncture site and flank/retroperitoneal area must precede any pharmacological or fluid interventions.
Direct assessment confirms the complication and dictates immediate life-saving actions, such as applying manual pressure.

Anahtar Kavram

Early recognition of retroperitoneal hemorrhage and hypovolemic shock post-femoral arterial puncture.
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Physiological Adaptation

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