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    Ati Rn pharmacology proctored exam 2023

    A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Apply a warm, moist compress: A cool and edematous IV site indicates infiltration, where IV fluid leaks into surrounding tissues. Applying a warm, moist compress promotes vasodilation and absorption of the infiltrated solution, reducing swelling and discomfort. B. Maintain the extremity below the level of the heart: Keeping the extremity below heart level can worsen edema by promoting fluid pooling in the affected area. The limb should instead be elevated to facilitate fluid drainage. C. Slow the IV solution rate: Simply slowing the infusion does not resolve infiltration. The infusion must be stopped immediately to prevent further tissue injury and discomfort. D. Initiate a new IV distal to the initial site: A new IV should never be started distal to the infiltrated site because of compromised venous return and tissue damage. A new site should be established proximal to or in a different extremity altogether.

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