A client tells the nurse that the skin of his intravenous infusion feels cold and there is some fluid leaking on the bed. Which of the following should the nurse do?
1. Assess the intravenous infusion catheter, stop the infusion, apply comfort measures, and treat the site per organization policies.
2. Clean the leaking fluid from the client's skin and change the bed linens.
3. Wrap the intravenous site with gauze to absorb leakage.
4. Tell the client that the fluid was in the refrigerator and that cold skin is expected.
Assess the intravenous infusion catheter, stop the infusion, apply comfort measures, and treat the site per organization policies.
Rationale: The nurse needs to adjust to the change in the client's intravenous fluid access site by assessing the site, stopping the infusion, applying comfort measures, and treating the site according to organization policies. The nurse should not ignore the client's complaint of cold skin and just clean the site and change the bed linens. Wrapping the site with gauze to absorb the leakage and telling the client that the fluid was in the refrigerator and cold skin is expected do not reflect adjusting care according to the client's clinical condition.
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