Asked by Skyya Edwards on Jun 25, 2024
Verified
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action?
A) Record a phlebitis grade of 4.
B) Assign an infiltration grade.
C) Apply moist compress.
D) Discontinue the IV.
Red Streak
A red line or mark on the skin, often indicative of infection or inflammation of the lymphatic system.
Warm to Touch
Refers to a condition where a part of the body feels unusually hot when touched, often indicating inflammation or infection.
Phlebitis Grade
A classification system used to indicate the severity of phlebitis, an inflammation of the veins, typically in the legs.
- Ensure the safe handling of intravenous therapy, including the oversight of IV lines and the process of blood transfusions.
- Identify and avert possible complications associated with intravenous therapy.
Verified Answer
VT
Vikram ThindJun 30, 2024
Final Answer :
D
Explanation :
The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued.
Learning Objectives
- Ensure the safe handling of intravenous therapy, including the oversight of IV lines and the process of blood transfusions.
- Identify and avert possible complications associated with intravenous therapy.