Editing Reduction of Risk Potential – RN Practice Questions (section)

==Question 4==
Four hours after a femoral cardiac catheterization, a client reports new dull back and flank pain. Vital signs are blood pressure 88/54 mm Hg, heart rate 118 beats per minute, and respirations 24 breaths per minute. The groin dressing is dry and intact. What should the nurse do first?
# Reposition the client and administer the ordered analgesic.
# Apply additional pressure to the groin site and recheck in 15 minutes.
# Notify the provider immediately and prepare for evaluation of retroperitoneal hemorrhage.
# Ambulate the client to relieve the muscular back discomfort.

'''Answer:''' Option 3. Notify the provider immediately and prepare for evaluation of retroperitoneal hemorrhage.

''Rationale:'' A dry groin dressing does not exclude bleeding, because blood from the femoral puncture can track into the retroperitoneal space. New back or flank pain with tachycardia and hypotension after femoral access is the classic presentation and requires urgent evaluation, typically with imaging and serial hemoglobin. Options 1 and 4 delay recognition of hemorrhage and mobilization is contraindicated. Option 2 does not address bleeding that is not at the surface and wastes critical time.