Question

A nurse is assessing a client receiving intravenous potassium chloride. The client verbalizes pain to the IV site. The site appears swollen and is warm to touch. Which action does the nurse perform?

Decrease the rate of the infusion

Apply ice to the IV access site

Inform the client that this is an expected finding

Discontinue the IV catheter

Answer 1

The nurse should discontinue the IV catheter if a client verbalizes pain to the IV site that appears swollen and warm to touch.

Step-by-step explanation:

The nurse should discontinue the IV catheter.

If a client verbalizes pain to the IV site and the site appears swollen and warm to touch, it could indicate phlebitis, which is inflammation of the vein. In this case, it is important for the nurse to discontinue the IV catheter to prevent further complications.

Continuing the infusion or applying ice to the IV access site would not address the underlying problem of phlebitis and could potentially worsen the condition.

Informing the client that this is an expected finding would be incorrect, as pain, swelling, and warmth are not expected findings with a properly functioning IV site.