The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?
A. (incorrect) A new IV will be started in the right hand after the IV is discontinued.
B. (correct) The client has signs of phlebitis and the IV must be removed to prevent further complications.
C. (incorrect) Depending on the health-care facility, this may or may not be done, but client care comes before documentation.
D. (incorrect) A warm washrag placed on an IV site sometimes provides comfort to the client. If this is done, it should be done for 20 minutes four (4) times a day.
TEST-TAKING HINT: The question is asking for a first action, which means all of the options may be actions the nurse would implement, but only one is priority. In general, priority actions are to stop the problem, continue treatment, treat the problem, and then document.