Question

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Answer 1

When an IV site is painful and medication administration is refused, the nurse should assess for complications, report findings to a healthcare provider, and provide appropriate care like warm compresses or elevation. Further interventions or antibiotic treatment should continue as directed by the physician.

Step-by-step explanation:

When a client expresses pain at an intravenous (IV) site and refuses a flush to assess the site, the nurse should prioritize the patient's comfort and safety. The first intervention should be to stop any attempts of administering medication or a flush. Next, the nurse needs to carefully assess the site for signs of complications such as swelling, redness, warmth, or drainage, which might indicate phlebitis, infiltration, or infection. If signs of infection are present, as in the case of Barbara who has redness and warmth at her catheter site with a fever, these symptoms should be reported to the healthcare provider promptly.

Following assessment and reporting, the nurse should provide appropriate interventions, such as applying a warm compress if indicated, elevating the extremity, and possibly removing the IV catheter if ordered by the healthcare provider. Any further treatment for the infection, like the antibiotics already prescribed (like oxacillin), should continue as per the physician's directions. It's important to monitor the patient's response to the intervention and ensure that alternative routes of administration for required medications are considered if IV therapy is not possible.