The nurse is preparing to administer 500 mL of 0.9% Normal Saline to a client with a peripheral IV. Upon assessment, the nurse notes redness, swelling, and pain at the insertion site, and the IV is no longer infusing. Which action should the nurse take NEXT?
- ADocument the findings and continue monitoring the site.
- BAttempt to flush the IV with 10 mL of normal saline.
- CDiscontinue the current IV and restart it in a new location.
- DApply a warm compress to the site and elevate the extremity.
Show answer & explanationAnswer & explanation
Correct answer: C. Discontinue the current IV and restart it in a new location.
The client's symptoms (redness, swelling, pain) at the IV site, along with the IV not infusing, are classic signs of infiltration or phlebitis. In this situation, the IV is no longer patent or safe for use. The priority action is to discontinue the compromised IV and restart it in a new, healthy site to ensure medication delivery and prevent further tissue damage.
Why the other options are wrong
- A. Documenting is important, but simply monitoring an infiltrated or phlebitic IV without intervention is inappropriate and unsafe.
- B. Attempting to flush a compromised IV can worsen infiltration or cause further discomfort/damage.
- D. Applying a warm compress and elevating the extremity are supportive measures after discontinuing the IV, not the immediate next step.
IV Infiltration/Phlebitis
Infiltration occurs when IV fluid leaks into surrounding tissue, causing swelling, coolness, and pallor. Phlebitis is inflammation of the vein, characterized by pain, redness, and warmth. Both render the IV site unusable and require prompt discontinuation and re-siting.
- Infiltration: swelling, cool, pallor.
- Phlebitis: pain, redness, warmth.
- IV no longer patent or safe.
- Discontinue and restart IV.
Memory trick: Red, painful, swollen? Pull it out and start anew!