Medical Surgical Myocardial Infarction #5

Question

The nurse received report from the cardiac catheterization team following a percutaneous coronary intervention (PCI) procedure. During the assessment, the nurse notices a blood-soaked dressing and bleeding from the femoral artery access site. What action should the nurse perform first?

Answers

  1. Add another dressing layer on top of the saturated dressing.
    • Rationale:

      This answer is not correct because active bleeding from an arterial site requires quick action by the nurse, including calling for help and applying pressure to the site immediately is necessary to keep the client alive. Adding another dressing layer on top of the saturated dressing of an arterial site will not stop the bleeding and delay important life-saving actions.

  2. Raise the leg and place the client in trendelenburg position.
    • Rationale:

      This answer is not correct because raising the lower extremity or placing the client in trendelenburg will not stop the bleeding. Sometimes this is used to elevate the blood pressure, but never before other actions to stop the bleeding have occurred. Quick action by the nurse, including calling for help and applying pressure to the site immediately is necessary to keep the client alive.

  3. Call for help and apply pressure to the site immediately.
    • Rationale:

      This answer is correct because the major sign of bleeding or hemorrhage from an artery is obvious external bleeding noted on bandages or hard, indurated areas near the site, such as the board-like abdomen for abdominal hemorrhage. The client will quickly experience shock from arterial bleeding, including decreasing blood pressure, increasing heart rate, decreasing level of consciousness, and cool extremities. Quick action by the nurse, including calling for help and applying pressure to the site immediately is necessary to keep the client alive.

  4. Immediately pull on the femoral sheath until it is out of the femoral site.
    • Rationale:

      This answer is not correct because increased bleeding and possible hemorrhage may occur if the femoral sheath is pulled out. Quick action by the nurse, including calling for help and applying pressure to the site immediately is necessary to keep the client alive.

Overview

Hemorrhage can occur quickly when bleeding is occuring from an artery. Quick action by the nurse, including calling for help and applying pressure to the site immediately is necessary to keep the client alive.

Explanation

Learning Outcomes

Hemorrhage is excessive bleeding that can lead to shock and death. It is especially a risk if the client is bleeding from an artery since arteries are high pressured vessels directly coming from the heart. The major sign of bleeding or hemorrhage from an artery is obvious external bleeding noted on bandages or hard, indurated areas near the site, such as the board-like abdomen for abdominal hemorrhage. The client will quickly experience shock from arterial bleeding, including decreasing blood pressure, increasing heart rate, decreasing level of consciousness, and cool extremities. Quick action by the nurse, including calling for help and applying pressure to the site immediately is necessary to keep the client alive.

Test Taking Tip

When a person is bleeding, you must stop the bleeding! ABCs first!

Video Rationale