The nurse is checking on the patient who underwent cardiac catheterization via the femoral artery 2 hours after the procedure. The patient appears to be sleeping and the nurse notes that the bruise at the insertion site has increased in size since the last assessment. Which action does the nurse take first?

Check the carotid pulse. The patient is at an increased risk for severe bleeding following a cardiac catheterization. Therefore, the nurse must prioritize the assessment to determine if the patient is in imminent danger of exsanguination by checking the carotid pulse. If the carotid pulse is adequate in rate and intensity, the nurse can then assess the pedal pulse distal to the insertion site to ensure adequate blood flow is reaching the extremity. Evaluation of capillary refill time can be performed if the carotid pulse is weak, thready, and/or rapid. Palpation of the insertion site for a hematoma is likely not advised due to the risk for disruption of clot formation and further bleeding.

The nurse is checking on the patient who underwent cardiac cathet...

Category: Physiological Adaptation
Difficulty: 6

Topics: Cardiovascular Disease Prevention Hematology/Oncology

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