Question

A nurse is assessing a client's peripheral intravenous (IV) access prior to initiating a blood transfusion. Which finding will prompt the nurse to initiate new venous access?

The IV site is on the client's wrist.

The catheter has been in place for 72 hours.

The skin around the IV site is cool to the touch.

The IV catheter is a 20-gauge.

Answer 1

A cool IV site may indicate poor perfusion or infiltration, requiring new venous access. The IV's wrist location, 72-hour duration, or 20-gauge catheter alone don't necessitate a new site unless complications are present.

Step-by-step explanation:

When assessing a client's peripheral intravenous (IV) access prior to initiating a blood transfusion, the nurse should look for signs of potential complications. A finding that would prompt the nurse to initiate new venous access would be a complication such as phlebitis, infiltration, infection, or a significant obstruction. In this scenario, the fact that the skin around the IV site is cool to the touch could indicate poor perfusion or infiltration, which is a potential complication where IV fluids enter the surrounding tissue instead of the vein. This would necessitate the establishment of new venous access.