The nurse evaluates the venipuncture site before leaving the client's room with the blood specimen. Which nursing observation is an unexpected outcome?
1. A dot of blood covers the venipuncture site.
2. Heart rate is stable and regular at 80 beats/min.
3. A soft subcutaneous lump appears at venipuncture site.
4. The client complains of stinging with removal of needle.
3
3. A soft subcutaneous lump at the venipuncture site after withdrawing the needle potentially indicates hematoma formation; this is undesirable because it increases the risk of client infection at the site and is likely to cause client discomfort.
1. A dot of blood can indicate leakage from the venipuncture site but is usually a be-nign finding indicating clot formation. The nurse should pause and assess the regional tissue to rule out subcutaneous bleeding.
2. A stable heart rate and rhythm is a highly desirable outcome of venipuncture.
4. Stinging on removal of the needle is an expected finding.
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