The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? A)Client scheduled for discharge who has had a peripheral IV in place for 84 hours B)Client with a do-not-resuscitate prescription who has swelling at the IV site C)Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago D)Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

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11ecbb05_cb11_ba56_b433_0fc71d18625f_MD0009_00 During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. Interventions include: Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) Elevating the affected extremity to decrease swelling Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs. (Option A) Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority. (Option C) It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority. (Option D) An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag. Educational objective: The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

The Nurse Is Caring for a Group of Clients