The nurse observes the client's left cephalic IV site for coolness, edema, and mild tenderness. The IV infuses at the prescribed rate. Which should the nurse implement?
1. Instruct client to elevate arm on two pillows.
2. Discontinue the IV and start one in right arm.
3. Apply a warm, moist compress to the IV site.
4. Document the findings and reassess in 2 hours.
2
2. The client IV site is infiltrated, so the nurse should discontinue it and start another IV, 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 collaborate with the provider to apply a warm, moist compress to facilitate healing and provide comfort.
1. After the nurse discontinues the IV, the nurse instructs the client to elevate the arm to reduce edema because this technique facilitates venous return.
3. A warm moist compress is a reasonable intervention after the catheter is removed. The nurse should discontinue the IV, start a new IV, document the findings and fol-low-up nursing interventions, and continue to assess the old and the new IV sites.
4. The nurse must discontinue an infiltrated IV to prevent serious phlebitis or regional infection.
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