Question

The nurse notices failure of flow in the drip chamber with the roller clamp open and an absence of swelling at the insertion site. What should the nurse do? (Select all that apply.) The nurse should:

A. Attempt forceful flushing to achieve catheter patency without having to relocate the IV.
B. Determine patency by aspirating for a blood return.
C. Inject heparin flush solution into the nearest port of the catheter.
D. Apply a warm pack to the IV site.
E. Check for kinking of IV tubing.

Answer 1

When encountering a failure of flow in the drip chamber with the roller clamp open and no swelling at the insertion site, the nurse should perform forceful flushing, aspirate for a blood return, and check for kinking of IV tubing.

Step-by-step explanation:

When the nurse notices failure of flow in the drip chamber with the roller clamp open and an absence of swelling at the insertion site, there are several actions that the nurse should take:

1. Attempt forceful flushing to achieve catheter patency without having to relocate the IV. This involves pushing normal saline solution through the catheter with enough pressure to clear any blockages.
2. Determine patency by aspirating for a blood return. This involves attaching a syringe to the catheter and gently pulling back to check for a blood return.
3. Check for kinking of IV tubing. This involves making sure that the tubing is not twisted or bent, which can obstruct the flow of fluids.

Injecting heparin flush solution into the nearest port of the catheter and applying a warm pack to the IV site are not appropriate actions in this situation.