A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch
What is the nurse's initial action?
a. Record a phlebitis grade of 4.
b. Assign an infiltration grade.
c. Apply moist compress.
d. Discontinue the IV.
ANS: D
The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued.
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