The client with hypokalemia is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000-mL solution of dextrose 5% in 0.45% saline. The client says that the area around the IV site burns. What is the nurse's best first action?
A. Notify the physician.
B. Check for a blood return.
C. Document the finding as the only action.
D. Change the solution to dextrose 5% in 0.45% saline.
D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and then assess for a blood return. A blood return alone does not mean that the solution isn't also leaking into the surrounding tissue through a break in the blood vessel wall, even though the needle itself may remain in the vein.
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