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. Apply a warm compress: Warm compresses are used to promote absorption and comfort after infiltration occurs, but they do not address the immediate risk of tissue injury caused by ongoing IV fluid leakage. B. Stop the infusion: Edema and cool skin indicate infiltration, where IV fluid enters surrounding tissue instead of the vein. Stopping the infusion immediately prevents further tissue damage and potential complications such as necrosis or infection. C. Elevate the arm: Elevation can help reduce swelling and promote venous return, but it does not stop the ongoing infiltration. It is an adjunctive measure rather than the first action. D. Document the infiltration: Documentation is essential for legal and care continuity purposes, but it follows immediate interventions that address patient safety and prevent further injury.