Difficulty: Medium
Average Score: 75%
Simulated
A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?
Correct answer
B
Rationale
Correct Answer: B - Remove the IV saline lock.
Rationale: Pain above the catheter site during flushing could indicate catheter-related phlebitis, a common complication of IV therapy. Removing the IV saline lock is crucial to prevent further irritation, infection, or complications. This action allows for a thorough assessment of the catheter site and the need for further interventions such as a new IV placement or medication to address the inflammation.
Incorrect Choices:
A: Applying a warm compress may provide temporary relief but does not address the underlying issue of catheter-related phlebitis.
C: Injecting the solution more slowly does not address the cause of pain and could potentially worsen the situation if there is an underlying issue with the catheter.
D: Applying firm pressure to the plunger may cause discomfort to the client and does not address the root cause of pain above the catheter site.
Rationale: Pain above the catheter site during flushing could indicate catheter-related phlebitis, a common complication of IV therapy. Removing the IV saline lock is crucial to prevent further irritation, infection, or complications. This action allows for a thorough assessment of the catheter site and the need for further interventions such as a new IV placement or medication to address the inflammation.
Incorrect Choices:
A: Applying a warm compress may provide temporary relief but does not address the underlying issue of catheter-related phlebitis.
C: Injecting the solution more slowly does not address the cause of pain and could potentially worsen the situation if there is an underlying issue with the catheter.
D: Applying firm pressure to the plunger may cause discomfort to the client and does not address the root cause of pain above the catheter site.