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Zorluk: OrtaReduction of Risk Potential

During bedside shift report, the nurse assesses a client who underwent a percutaneous coronary intervention via the right femoral artery four hours ago. The client suddenly reports acute, deep lower back pain. The nurse notes a heart rate of 118 beats per minute and a blood pressure of 92/58 mm Hg, compared to baseline vital signs of 78 beats per minute and 124/76 mm Hg. The right groin dressing remains dry and intact. Which of the following is the most appropriate initial action by the nurse?

  1. Notify the healthcare provider immediately and prepare to administer intravenous fluids.Cevap
  2. B
    Elevate the head of the bed to a high-Fowler's position to reduce tension on the lower back.
  3. C
    Administer the prescribed as-needed intravenous opioid analgesic to manage the reported pain.
  4. D
    Delegate the continuous monitoring of vital signs to the unlicensed assistive personnel.

Cevap

Notify the healthcare provider immediately and prepare to administer intravenous fluids.
The correct answer identifies that the client is experiencing a retroperitoneal hemorrhage. Tachycardia, hypotension, and severe lower back pain after a femoral catheterization are hallmark signs of this concealed bleeding. Immediate notification of the provider and preparation for fluid resuscitation are critical risk reduction measures to prevent severe shock.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and vital sign trends.
The client has new-onset severe back pain, tachycardia, and hypotension four hours after a femoral arterial procedure.
Identifying acute changes from baseline is essential for early complication detection.
2
Correlate the clinical findings with potential procedural complications.
The combination of symptoms strongly indicates a retroperitoneal hemorrhage, despite a dry external dressing.
Blood from the femoral artery can leak backward into the retroperitoneal space, causing flank or back pain and concealed hypovolemia.
3
Determine the priority nursing intervention.
The nurse must immediately alert the healthcare provider and prepare to restore intravascular volume.
Rapid medical intervention and fluid resuscitation are required to mitigate the risk of severe hemorrhagic shock and potential cardiovascular collapse.

Anahtar Kavram

Early recognition and mitigation of retroperitoneal hemorrhage following femoral arterial catheterization.
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Konular

Reduction of Risk Potential

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