A client returns to the unit following a cerebral angiogram via the femoral artery that was performed two hours ago. In assessing this client, which finding requires immediate intervention by the nurse?
Explanation & Rationale
Rationale: A. Blood pressure measurement of 122/84 mm Hg and a heart rate of 88 beats/minute: These vital signs are within acceptable limits and do not indicate an acute complication following a cerebral angiogram. No immediate intervention is required for these values. B. No urinary output measured since the procedure: While monitoring urine output is important, a two-hour gap post-procedure may not yet indicate a critical problem. The nurse should continue to monitor and assess, but this is not the most urgent finding. C. Diminished volume of right dorsalis pedis pulse: A weak or absent peripheral pulse following femoral artery catheterization may indicate arterial obstruction, thrombus, or compromised distal perfusion. Immediate intervention is required to restore circulation and prevent tissue ischemia. D. Client reports feeling hot during the procedure and cold afterward: These sensations may reflect normal physiological responses to contrast media or procedural stress. While worth noting, they do not require urgent intervention compared to compromised limb perfusion.