A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
ANS: B, D, E
In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.
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