VATI Fundamental Practice Exam

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If a nurse notices redness and swelling at an IV site, what is the first action?

Notify the physician

Discontinue the existing IV line

Discontinuing the existing IV line is the appropriate first action when redness and swelling are observed at the IV site. This action is crucial because these signs can indicate potential complications such as phlebitis, infiltration, or infection. By removing the IV, the nurse prevents further irritation to the site and avoids the risk of compounding the issue.

After discontinuation, the nurse can then assess the client for pain or other symptoms, apply warm compresses if necessary, and notify the physician as part of the follow-up care. However, immediate removal of the source of the problem is the most critical first response to ensure patient safety and prevent further complications.

Apply a warm compress

Assess the client for pain

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