When assessing a client's peripheral IV site, the nurse notices edema and tenderness above the site. What action does the nurse take first?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter.
d. Stop the infusion of IV fluids.
D
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed by institutional policy and may help speed circulation to the area.
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