Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken?

Question

1. Discontinue this infiltrated lock and restart another site for medication administration.
2. Slowly infuse 1 mL of saline into the lock, assessing for infiltration.
3. Reinsert the needle into the lock and aspirate using more pressure.
4. Pull the intravenous catheter out 1/8 inch and attempt aspiration.

Answer 1

Correct Answer: 2
Rationale 1: Simple lack of blood upon aspiration does not indicate infiltration, so there is no need to discontinue the site.
Rationale 2: While the presence of blood upon aspiration confirms that the catheter is in a vein, the absence of blood does not rule out correct placement. If no blood returns, the nurse should slowly infuse 1 mL of saline into the lock while assessing the site for infiltration. If there is no infiltration present, the nurse should administer the medication.
Rationale 3: Often the reason for absence of blood return is that the vessel has collapsed around the catheter from the pressure of aspiration. Increasing the pressure will not increase the likelihood of blood return.
Rationale 4: Pulling the intravenous catheter out 1/8 inch will not increase the likelihood of blood return and may make the site more unstable.