Author Question: A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. ... (Read 103 times)

tatyanajohnson · **on:** Jun 25, 2018

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.

Question 2

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

a. The initial site dressing is 3 days old.
b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.

ttt030911 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse should stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.

Answer to Question 2

ANS: D
Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV should have one, but this does not take priority over the client whose arm is swollen.