Question

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.

E FLAG
The nurse is assessing the client. Which of the following actions should the nurse take?
Select all that apply.
Exhibit 1
Nurses' Notes
Day 1:
Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well.
Day 2:
IV site edematous. Skin surrounding catheter site taut, blanched, and cool to
touch. IV fluid not infusing.
Stop the IV Infusion.
Elevate the client's left arm.
Apply heat to the dienst hand.
Place a pre
Start a new IV in us
UE

Answer 1

The nurse should stop the IV infusion, elevate the client's left arm, and apply heat to the distal hand.

Step-by-step explanation:

The nurse should take the following actions:

1. Stop the IV infusion: The IV fluid is not infusing, indicating a potential problem with the IV line or catheter.
2. Elevate the client's left arm: Elevating the arm can help reduce edema and improve blood flow.
3. Apply heat to the distal hand: Applying heat can help dilate blood vessels and improve circulation.

Answer 2

The nurse should stop the IV infusion, elevate the client's left arm, and apply heat to the distal hand.

Step-by-step explanation:

Based on the given information, the nurse should take the following actions:

1. Stop the IV infusion
2. Elevate the client's left arm
3. Apply heat to the distal hand

The IV site is showing signs of infiltration, which is characterized by swelling, blanching, and coolness to the touch. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of flowing into the vein. Stopping the IV infusion will prevent further infiltration, elevating the arm will help reduce swelling, and applying heat can promote blood flow and help dissolve the infiltrated fluid.