The nurse observes bleeding on the dressing of an IV insertion site. Which should the nurse implement?
1. Examine insertion site.
2. Reinforce the dressing.
3. Apply warm compress.
4. Remove the IV quickly.
1
1 and 4. The nurse assesses the insertion site to determine whether the blood is draining from the insertion site; if the blood is from the insertion site, the nurse must discontinue the IV and insert a new IV in another location. The nurse discontinues the IV because a draining wound provides a mode of entry for pathogens to increase the risk of infection.
2. Reinforcing a leaking IV site is contraindicated because it increases the risk of in-fection and more serious complications, including thromboembolic events and sepsis.
3. A warm compress causes vasodilation to increase regional blood flow. Draining blood is an unexpected outcome of an IV insertion site and the duty the nurse owes to the client is to resolve the problem.
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