The nurse observes that the patient's left cephalic intravenous (IV) site is cool, swollen, and mildly tender, although the IV line is infusing at the prescribed rate. Which action should the nurse take first?
a. Instruct the patient to elevate his or her arm on two pillows.
b. Discontinue the IV infusion and start one in the right arm.
c. Apply a warm, moist compress to the IV site.
d. Reassess the IV site in 2 hours for any change.
B
The patient's IV site is infiltrated; thus the nurse should discontinue the infusion immediately and start another IV infusion, preferably in the other arm. If the right arm is contraindicated, the nurse chooses a subsequent site that is proximal to the original site to avoid additional irritation of the vein. An infiltrated IV site increases the risk of regional phlebitis. The nurse should colla-borate with the healthcare provider to apply a warm, moist compress to facilitate healing and provide comfort once the IV line has been removed. After the nurse discontinues the IV infusion, he or she instructs the patient to elevate the arm to reduce edema because this technique facili-tates venous return.
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