A nurse is assisting with the care of a client who has pneumonia. For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

Administer phytonadione (Vitamin K): Contraindicated There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition. Apply cool compress to the extremity: Anticipated A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues. Elevate extremity: Anticipated Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery. Suggest irrigating the IV catheter: Contraindicated Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately. Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration. Send the catheter tip for culture: Anticipated Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.