In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority?
a. Applying continuous heat
b. Continuing to monitor site
c. Elevating the extremity
d. Removing the catheter
D
The clinical manifestations described are those associated with phlebitis. Phlebitis is an inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by mechanical forces associated with the IV device, or by chemical factors related to the composition and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes four times daily after the catheter is removed. The site needs to be monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.
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