Which client situation would the nurse need to report to the health care provider as soon as it is noted?
1. The client with normal saline infusing IV who complains of pain at the IV site, noted to be slightly red
2. The client with a continuous infusion of heparin whose IV site is noted to be red, edematous, and painful to touch
3. The client who accidentally discontinued an IV and requires a new IV insertion
4. The client whose saline lock is not patent, and who requires a new lock to be inserted
Correct Answer: 2
The client who has a heparin infiltrate might require treatment to prevent tissue damage or rapid absorption of infiltrated heparin. The health care provider should be notified, and orders taken as indicated. The other situations do not require immediate health care provider notification, because the nurse can restart an IV as indicated without approval from the health care provider.
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