A nurse is caring for a client receiving intravenous (IV) therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?

Choice A rationale Elevating the extremity may aid in reducing edema by promoting venous and lymphatic return through gravity. However, this is a secondary intervention. The primary concern is stopping the inflammatory insult caused by the IV fluid or catheter, which is achieved by discontinuing the infusion immediately before any other action to prevent further tissue damage. Choice B rationale Inserting a new IV catheter is necessary after the affected one is removed, but it's not the first step. The priority is to stop the immediate insult and prevent further complications like cellulitis or abscess formation from the current, inflamed site. The opposite extremity is often chosen for the new site to avoid bilateral issues. Choice C rationale Applying warm, moist compresses is a correct subsequent intervention after discontinuing the IV. The heat promotes vasodilation, increasing circulation to the inflamed area, which aids in the absorption of fluids and reduces discomfort, a process known as phlebitis management. This is a treatment, not the initial safety action. Choice D rationale Discontinuing the existing IV infusion is the priority action. The signs (redness, warmth, swelling) strongly suggest phlebitis (inflammation of the vein) or infiltration (non-vesicant fluid leakage into surrounding tissue). Immediate removal prevents further chemical or mechanical irritation and potential progression of the inflammatory response or tissue damage.