A client complains of heaviness and swelling in the extremity of the intravenous infusion. The nurse would first:
1. Discontinue the catheter.
2. Flush the catheter.
3. Document the finding.
4. Notify the physician.
Discontinue the catheter.
Rationale: The nurse should discontinue the catheter when any sign of phlebitis occurs. Flushing the catheter will cause further irritation of the surrounding tissue. Documenting the finding is necessary; however, it is not the initial intervention that should be implemented. Notifying the health care provider is necessary to obtain treatment of the infiltration, but this is not the initial intervention that would be performed.
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