The client complains of loss of motion in the arm with an IV infusing. The nurse assesses the IV site and notes that the site is red, warm, and swollen. What is the most likely cause and what action should be taken first?
a. tissue necrosis and the nurse should monitor the site
b. pyrogenic reaction and the nurse should stop the infusion immediately.
c. thrombophlebitis and the nurse should stop the infusion immediately.
d. fluid overload and the nurse should decrease the flow rate and notify the health care provider.
ANS: B
Feedback
A Incorrect: These are not manifestations of tissue necrosis.
B Correct: A cardinal manifestation is the loss of motion in the limb where the fluids are infusing. The nurse should stop the infusion immediately and follow the facility protocol related to pyrogenic reactions.
C Incorrect: Although redness and warmth are manifestations of thrombophlebitis, the group of manifestations indicate a pyrogenic reaction.
D Incorrect: These are not manifestations of fluid overload.
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