The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling
What action should be taken by the nurse?
1. Slow the IV infusion and reassess the area in 15 minutes.
2. Place a cool pack over the IV site and vein.
3. Discontinue the IV and place a warm pack on the area.
4. Call the physician for direction.
Correct Answer: 3
Rationale 1: Simply slowing the IV will not prevent further damage to the vein and will also alter the amount of IV fluid and medication the client is receiving.
Rationale 2: A cool pack over the IV site will not prevent additional damage to the vein.
Rationale 3: This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place a warm pack on the area.
Rationale 4: This assessment and evaluation are within the scope of nursing practice, so at this point, collaboration with the physician is not necessary.
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