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    HESI Exit RN with NGN Proctored Exam

    While the nurse is preparing a scheduled IV medication, the client states 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

    Choice A reason: Reviewing the medical record for the date of insertion is important but does not address the immediate concern of pain or potential complications at the IV site. Choice B reason: Applying ice and then a warm compress may be used for phlebitis or infiltration, but if the client is experiencing pain, the priority is to address the potential for complications. Choice C reason: Documentation is a necessary step, but it should not be the first action taken when a client reports pain at the IV site. Choice D reason: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.

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