NursingPlex
    Sign In
    ATI LPN Comprehensive Predictor 2023 Proctored Exam

    A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

    Explanation & Rationale

    A. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues. B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury. C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues. D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.

    🔒 Submit your answer to reveal