A nurse is caring for a client receiving 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 Phlebitis and infiltration represent serious complications of intravenous therapy requiring immediate intervention to prevent further tissue damage. Redness, warmth, and swelling at the site indicate an inflammatory response in the vein or surrounding tissue. The first priority in clinical practice is to remove the source of irritation. By discontinuing the infusion immediately, the nurse stops the delivery of potentially irritating medications or fluids, thereby limiting the extent of the vascular injury and initiating the recovery process. Choice B rationale Elevation of the affected extremity is a supportive intervention used to reduce edema by promoting venous return and lymphatic drainage. While this is a helpful secondary action once the primary threat is addressed, it does not stop the underlying cause of the irritation or inflammation. The nurse must prioritize stopping the infusion and removing the catheter before implementing comfort measures. This action helps alleviate localized pressure and swelling but remains a lower priority than discontinuation of the IV. Choice C rationale The application of warm, moist compresses is a common nursing intervention designed to promote vasodilation and improve local circulation to the injured area. This can help the body reabsorb fluid and decrease the discomfort associated with phlebitis. However, applying heat while an irritating catheter is still in place is inappropriate. This step should only be taken after the IV has been successfully discontinued and the site has been secured, making it a subsequent rather than initial action. Choice D rationale Establishing new vascular access in the opposite extremity is necessary to ensure the client continues to receive prescribed fluids and medications. However, the immediate safety of the client regarding the current inflamed IV site takes precedence over the insertion of a new line. The nurse must first manage the potential complication at the left forearm site. Only after the problematic IV is discontinued and the site is treated should the nurse focus on initiating access elsewhere.