The nurse discontinues the client's IV prior to discharge. After removing the catheter, which actions by the nurse are appropriate?
1. Applying pressure to the insertion site until bleeding stops
2. Examining the removed catheter to ensure that it is intact
3. Teaching the client to inform the nurse if the site begins to bleed at any time
4. Holding the client's extremity below the level of the heart if bleeding persists
5. Covering the venipuncture site with a sterile dressing
1, 2, 3, 5
Rationale 1: The nurse should apply pressure to the insertion site until bleeding stops.
Rationale 2: The nurse should examine the removed catheter to ensure that it is intact.
Rationale 3: The nurse should teach the client to inform the nurse if the site begins to bleed at any time.
Rationale 4: The client's extremity should be held above the level of the heart if bleeding persists.
Rationale 5: The nurse should cover the venipuncture site with a sterile dressing.
Global Rationale: The nurse should apply pressure to the insertion site until bleeding stops; examine the removed catheter to ensure that it is intact; teach the client to inform the nurse if the site begins to bleed at any time; and cover the venipuncture site with a sterile dressing. The client's extremity should be held above the level of the heart if bleeding persists.
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