# A nurse is caring for a 64-year-old client 2 hours after a diagnostic cardiac catheterization performed via the right femoral artery. The client reports increasing right groin discomfort, and the nurse notes a 4-cm hematoma at the access site, decreased dorsalis pedis pulse on the right compared to baseline, and oozing through the dressing. Vital signs: BP 96/58 mm Hg (baseline 132/78), HR 112 (baseline 78). Which actions are essential? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368186&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

A nurse is caring for a 64-year-old client 2 hours after a diagnostic cardiac catheterization performed via the right femoral artery. The client reports increasing right groin discomfort, and the nurse notes a 4-cm hematoma at the access site, decreased dorsalis pedis pulse on the right compared to baseline, and oozing through the dressing. Vital signs: BP 96/58 mm Hg (baseline 132/78), HR 112 (baseline 78). Which actions are essential? Select all that apply.

1

Reposition the client to high Fowler with right hip flexed at 90 degrees to relieve groin pressure

2

Have the client ambulate immediately to dislodge the hematoma and improve perfusion

3

Reassess and document distal pulses, color, capillary refill, and sensation of the right lower extremity every 15 minutes

4

Apply firm manual pressure 1 to 2 cm above the puncture site and notify the cardiologist immediately

5

Document the findings and reassess in 4 hours per the standard post-cath protocol

6

Obtain a stat CBC and prepare for possible blood transfusion if hemoglobin drops or hemodynamics worsen

## Explanation

Post-cath complications (hematoma, retroperitoneal bleed, pseudoaneurysm, distal ischemia) require immediate recognition and bedside intervention. Hypotension plus tachycardia plus new distal pulse decrease plus groin hematoma equals active bleeding with possible retroperitoneal extension. Required actions: (1) firm manual pressure 1 to 2 cm proximal to (above) the puncture site, with immediate cardiologist notification — bedside compression is the first-line hemostasis; (2) frequent (every 15 minute) distal limb assessment — distal pulse change signals limb ischemia from compromised flow or occlusion; (4) stat CBC for blood-loss quantification and transfusion preparation given hemodynamic instability. Ambulation (option 2) extends the bleed and dislodges hemostasis. Hip flexion (option 1) increases femoral pressure and bleeding; the affected leg should remain straight. Standard every 4 hour reassessment (option 5) is dangerously delayed for active bleeding — escalate now.

## In-depth explanation

Post-Cath Bleeding Recognition
Femoral access complications: hematoma, retroperitoneal bleed (back or flank pain), pseudoaneurysm (pulsatile mass with bruit), AV fistula, distal ischemia.

Red Flags in This Case
- BP drop 132 to 96
- HR 78 to 112
- New 4-cm hematoma plus oozing
- Decreased distal pulse
equals active bleeding plus possible distal ischemia

Immediate Actions
1. Firm pressure 1 to 2 cm proximal to puncture (above bleed)
2. Notify cardiologist STAT
3. Every 15 minute distal pulse, color, CR, sensation
4. Stat CBC, type and screen
5. Keep affected leg straight, HOB at or below 30 degrees
6. Prepare for possible compression device, US-guided thrombin injection, or surgical repair

Wrong Answers
3: Ambulation worsens the bleed.
5: Hip flexion increases pressure.
6: Every 4 hour interval is dangerously delayed for an active bleed.

NCSBN Theme
ROR — Post-procedure complications.

## Clinical scenario

Scenario
64-year-old, 2 hours post diagnostic cardiac cath via R femoral.

Findings
- Increasing R groin discomfort
- 4-cm hematoma plus oozing through dressing
- Decreased R dorsalis pedis pulse
- BP 96/58 (was 132/78)
- HR 112 (was 78)

Pattern
Hypotension plus tachycardia plus hematoma plus decreased distal pulse equals active bleed and possibly distal ischemia.

Required Response
Manual pressure proximal plus cardiologist STAT plus every 15 minute distal limb checks plus stat labs.

## Key concepts

- **Femoral access complications** — Post-cardiac-cath complications at the femoral arterial puncture: hematoma (most common, soft swelling), retroperitoneal bleed (high mortality, presents with back or flank pain plus hypotension out of proportion to visible bleeding), pseudoaneurysm (pulsatile mass with bruit, US-guided thrombin or compression repair), AV fistula (continuous bruit), distal ischemia (pulseless cold leg, cath or embolectomy).
- **Manual compression hemostasis** — First-line bedside intervention for post-cath bleeding. Apply firm direct pressure 1 to 2 cm proximal to (above) the puncture site, NOT directly over it, to compress the artery against the femoral head. Hold for 20 to 30 minutes minimum, longer if anticoagulated. Pulse must remain palpable distally to avoid total occlusion. Femstop or compression devices may follow.
- **Distal perfusion checks** — Critical post-cath assessment: distal pulses (dorsalis pedis, posterior tibial), color (pink versus pale or dusky), capillary refill (under 3 seconds), temperature (warm versus cool), sensation (intact versus numb), motor function. Compared to baseline AND to the contralateral limb. Loss of distal pulse with a cold pale leg equals a surgical emergency.

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