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    HESI RN Exit Exam IV Proctored Exam

    While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

    Explanation & Rationale

    RationaleA. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.C. Redressing the site without assessment does not address the client's complaint of pain.D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.

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