Question

The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first?

a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion

Answer 1

The nurse's first intervention should be to stop the IV infusion to prevent further injury, followed by assessing the IV site, notifying the physician, and documenting the findings.

Step-by-step explanation:

If a client receiving an IV reports that the area around the IV site burns, the first intervention that the nurse should perform is to stop the IV infusion. This is a safety precaution in response to a potential complication such as phlebitis, infiltration, or extravasation. Stopping the infusion prevents further injury to the tissue. After stopping the IV, the nurse should assess the site for signs of complications such as swelling, redness or a blood return. It is also important to notify the physician and document the findings as per the nursing protocol. Immediate action can prevent more serious damage and ensure patient safety.