Question

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

a. Apply a warm compress to the hematoma.

b. Administer pain medication.

c. Elevate the affected extremity.

d. Notify the healthcare provider immediately.

Answer 1

The nurse's priority is to notify the healthcare provider immediately.

Step-by-step explanation:

The nurse's priority in this situation is to d. Notify the healthcare provider immediately.

A hematoma at the insertion site following a cardiac catheterization can be a sign of a complication called a pseudoaneurysm. This occurs when the artery is damaged during the procedure, resulting in bleeding that forms a collection of blood under the skin. A decreased pulse rate in the affected extremity suggests that there may be compromised blood flow, which is a serious concern.

Applying a warm compress to the hematoma (a) may increase bleeding and should be avoided. Administering pain medication (b) may provide comfort, but it does not address the underlying issue. Elevating the affected extremity (c) may also be helpful in some cases, but it is not the priority intervention given the potential for compromised blood flow.