NCLEX-PN

Category - Physiological Adaptation

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A nurse is caring for a client with an intravenous catheter. On assessment, the nurse observes that the insertion site is warm and slightly edematous. Which of the following actions of the nurse is the most appropriate?

Stop the IV and remove the IV catheter
Apply a cold compress
Irrigate the catheter
Slow down the rate of infusion

Explanation

Answer: A - The most appropriate action of the nurse is to stop the IV and remove the IV catheter. After the catheter is removed and reinserted in the other extremity, the nurse can apply a warm compress to relieve the pain. Catheters are not irrigated if phlebitis is suspected. Slowing down the rate of infusion is more appropriate for fluid volume overload.

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