A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the pa-tient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch
What is the nurse's initial action?
a. Notify the physician.
b. Administer pain medication.
c. Discontinue the IV.
d. Start a new IV line.
ANS: D
The IV site has phlebitis. The nurse should start a new IV before discontinuing the old one be-cause it is important to always have an IV access site in a patient who is in hypertensive crisis. Then the physician can be notified. Pain medication may or may not need to be administered.
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