Question

While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?

a.Clean the site with alcohol
b.Assess the client's vital signs
c.Reinsert the needle
d.Document the findings and continue with the dressing change

Answer 1

The appropriate action to implement would be to assess the client's vital signs.

Step-by-step explanation:

Based on the finding of redness and warmth at the needle insertion site, the appropriate action to implement would be to assess the client's vital signs. This is important because redness and warmth can indicate inflammation or infection, and assessing vital signs can help determine if the client's condition is stable or deteriorating.

Cleaning the site with alcohol may be necessary later, but assessing vital signs should be the priority. Reinserting the needle is not the appropriate action as it can further exacerbate the situation. Documenting the findings and continuing with the dressing change is not sufficient as it does not address the potential underlying issue.