A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and the hand below the IV site feel like "pins and needles." Which action by the nurse is best?
a. Document the finding and continue to monitor the IV site.
b. Check for the presence of a strong blood return.
c. Discontinue the IV and restart it at another site.
d. Elevate the extremity above the level of the heart.
C
The sensation that the client has described is related to the IV needle touching the nerve or possibly transecting the nerve. This problem can lead to loss of function and the potential for permanent disability in the distal extremity. It is considered an emergency and the IV must be discontinued. Continuing just to monitor the IV site may lead to loss of function. The presence of blood return does not indicate absence of nerve damage. Elevation of the affected extremity does not ensure that the IV catheter has moved away from the nerve.
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