The nurse assesses the client's IV insertion site and notes it is warm, red, and tender. Which should the nurse implement first?
1. Slow the infusion rate.
2. Discontinue the IV site.
3. Apply a local anesthetic.
4. Apply warm compresses.
2
4. The nurse must discontinue the IV with a warm, red, and tender appearance be-cause these clinical indicators are consistent with an infection. The nurse also discon-tinues the IV to decrease the risk of sepsis, tissue loss, and a thromboembolic event.
1. If the site is infected, slowing the infusion rate is unlikely to help.
2. Applying a local anesthetic in improper therapy for the clinical indicators.
3. The nurse applies a warm compress after discontinuing the IV from the infected tissue.
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