Question

A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process?

1. IV is discontinued.
2. Warm compress applied to IV site.
3. Site reinspected for presence of swelling.
4. IV site observed as having significant swelling.

Answer 1

Option 3, which is inspecting the site for the presence of swelling.

Step-by-step explanation:

The nursing action that represents the evaluation phase of the nursing process in this situation is option 3, which is inspecting the site for the presence of swelling. The evaluation phase of the nursing process involves assessing the client's response to the nursing intervention and determining the effectiveness of the intervention in achieving the desired outcome. In this case, inspecting the site for swelling helps the nurse evaluate whether the infiltration has caused any adverse effects such as swelling.