A patient complains of heaviness and swelling in the extremity of the intravenous infusion. The nurse assesses that the skin around the site is stretched, firm, and cool. What primary nursing intervention is indicated?

Question

1. Flush the catheter.
2. Document the finding.
3. Notify the physician.
4. Discontinue the catheter.

Answer 1

4
Rationale 1: Flushing the catheter will cause further irritation of the surrounding tissue.
Rationale 2: Documenting the finding is necessary; however, it is not the initial intervention that should be implemented.
Rationale 3: Notifying the health care provider is necessary to obtain treatment of the infiltration, but this is not the initial intervention that would be performed.
Rationale 4: These findings indicate that the catheter is infiltrated. It should be discontinued.