CRNE Exam Prep

Category - Changes in Health

A client’s venipuncture site is swollen and cool to touch. The nurse occludes the vein proximal to the intravenous site. The intravenous fluid continues to flow. Which of the following is the next action of the nurse?
  1. Remove the intravenous device.
  2. Elevate the extremity.
  3. Apply compress.
  4. Rub the infiltrated area.
Explanation
Answer: A - The nurse should remove the intravenous device. If the intravenous fluid continues to flow, this indicates that the cannula is most likely outside the vein. After removal, the nurse elevates the extremity and applies the compress to relieve swelling and pain. Rubbing the infiltrated area could cause hematoma.
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