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1.ID: 383695688
A nurse notesthat the site of a client’s peripheral intravenous(IV) catheter is reddened, warm, painful,
and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the
nurse first:
Removesthe IV catheter Correct
Slows the rate of infusion
Notifiesthe healthcare provider
Checksfor loose catheter connections
Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by
client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV
catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion
and checking for loose catheter connections are not correct responses. The healthcare provider would
be notified if phlebitis were to occur, but this is not the initial action.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Eliminate
slowing the rate of infusion and checking the connection, because they are comparable or alike in that
they indicate continuation of IV therapy. Although the healthcare provider would be notified of this
occurrence, the word “first†should direct you to select the option of removing the IV catheter. Review
the signs of phlebitis and the actions to be taken when it occurs if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
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