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    Ati lpn pharmacology proctored exam 2023 retake 1

    A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?

    Explanation & Rationale

    A. Restart the infusion in the other extremity. While the IV infusion will need to be restarted in a new site, the priority after discontinuing the infusion is to manage the complications of IV infiltration. Restarting the infusion should be done after addressing the swelling and discomfort in the affected limb. B. Elevate the extremity. Elevating the extremity reduces swelling and promotes fluid reabsorption following an IV infiltration. This helps minimize pain, tissue damage, and further complications, such as compartment syndrome. It is the next priority action after stopping the infusion. C. Remove the catheter. The catheter should already be removed when the infusion is discontinued due to suspected infiltration. Keeping it in place could worsen tissue swelling and damage. If the catheter has not been removed yet, doing so is essential, but managing swelling and discomfort remains the priority after removal. D. Apply warm, moist compresses to the site. Warm compresses are typically used for extravasation of non-vesicant solutions to promote circulation and absorption. However, in cases of severe infiltration or swelling, cold compresses may be used initially to reduce inflammation before applying warmth. The priority action is elevation, followed by applying appropriate compresses based on facility protocol.

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