Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients is observed two hours after a cardiac catheterization. Which finding would prompt immediate assessment?

• A. Flexing and extending the legs two hours after a cardiac catheterization.
• B. Mild fever with throat discomfort.
• C. Nausea resolved with antiemetic.
• D. Stable vital signs with slight bruising at insertion site.

Answer: (A)

After a cardiac catheterization, especially via the femoral artery, the priority is to protect the access site and prevent bleeding by keeping the leg still and the site monitored during the early recovery period. Moving the leg by flexing and extending it can disrupt the site’s clot and hemostasis, increasing the chance of active bleeding or hematoma formation. That makes the finding of leg movement two hours after the procedure the one that warrants immediate assessment and intervention to ensure the site remains stable.

The other observations—mild fever with throat discomfort, nausea resolved with antiemetic, and stable vital signs with only slight bruising at the insertion site—are less concerning in the immediate post-procedure period, though the puncture site should still be monitored for changes. In general, keep assessing distal pulses, sensation, and movement of the extremity, and report any new bleeding, swelling, or changes in color or temperature at the site.