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    Ati pn 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

    Rationale: A. Apply a warm compress: Applying a warm compress may help promote absorption of infiltrated fluid and reduce discomfort, but it should not be the initial action. Warm compresses are appropriate only after the infusion is stopped and proper assessment is completed. B. Stop the infusion: The first priority when infiltration is suspected—evidenced by cool, edematous skin—is to stop the infusion immediately. Continuing the infusion could lead to worsening tissue damage or complications depending on the type of fluid or medication. C. Document the infiltration: Documentation is necessary but not the immediate priority. It should follow prompt clinical action to stop the infusion and prevent further harm to the surrounding tissue. D. Elevate the arm: Elevating the arm can help reduce edema, but this supportive measure should be done only after the infusion has been stopped. It does not address the root cause or prevent further infiltration.

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