NCLEX Question of the Day
Pharmacological and Parenteral Therapies QID 1236
A nurse assesses a client's peripheral IV site and notes redness, warmth, and palpable cord along the vein. The client reports tenderness at the site. The IV infusion is normal saline. What is the nurse's priority action?
Explanation
The assessment findings – redness (erythema), warmth, tenderness, and a palpable cord along the vein – are classic signs of phlebitis, inflammation of the vein. This is a common complication of peripheral IV therapy. The priority action when phlebitis is identified is to discontinue the infusion and remove the IV catheter immediately to prevent further irritation, pain, and potential complications like thrombophlebitis or infection.
After removing the catheter, warm compresses (not cold) are typically applied to alleviate discomfort and promote healing. Slowing the rate or continuing to monitor without removing the IV allows the inflammation to worsen. A new IV site should be established in a different location if IV therapy needs to continue.
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