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Zorluk: OrtaReduction of Risk Potential

A nurse is caring for a client who is 2 hours post-procedure following a right femoral cardiac catheterization. The client suddenly reports severe right groin pain. Upon inspection, the nurse notes a rapidly expanding, firm swelling at the catheter insertion site and a heart rate of 118 beats/minute. Which action should the nurse take first?

  1. A
    Instruct the nursing assistant to obtain an immediate set of vital signs.
  2. Apply firm, continuous manual pressure directly over the femoral insertion site.Cevap
  3. C
    Place the client in a high Fowler's position to optimize respiratory excursion.
  4. D
    Obtain a STAT 12-lead electrocardiogram to evaluate for acute myocardial ischemia.

Cevap

Apply firm, continuous manual pressure directly over the femoral insertion site.
The client's presentation of severe groin pain and a rapidly expanding swelling indicates a developing hematoma from active arterial bleeding at the femoral access site. In an acute bleeding scenario, the nurse's immediate priority is to address Circulation by applying firm, direct pressure to the site to achieve hemostasis and prevent hypovolemic shock.

Adım Adım Çözüm

1
Assess the clinical findings presented in the scenario.
The client is experiencing severe groin pain, a rapidly expanding firm swelling at the insertion site, and tachycardia.
Recognizing the signs of a specific post-procedure complication is necessary before determining the appropriate intervention.
2
Identify the underlying physiological threat.
The findings are classic indicators of a developing hematoma caused by active arterial bleeding.
Arterial hemorrhage can quickly lead to severe hypovolemia and shock if not immediately controlled.
3
Determine the priority intervention using the ABCs framework.
Direct manual pressure must be applied immediately to the femoral site.
Circulation takes precedence; stopping active blood loss is a higher priority than further diagnostic testing or delegation of duties.

Anahtar Kavram

Post-procedure hemorrhage management and prioritization
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Konular

Reduction of Risk Potential

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