HESI RN Exit VI Proctored Exam
Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?
Explanation & Rationale
A. Applying heat may be indicated later, but the first action should be to address the infiltration.B. Documenting the delay is important but not the immediate priority.C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.
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