What is the nurse's first action upon observing signs of phlebitis at an IV site?

What is the nurse's first action upon observing signs of phlebitis at an IV site?

• A. Apply warm compresses to the site
• B. Slow the IV infusion rate
• C. Notify the healthcare provider
• D. Remove the IV catheter

Answer: (D)

The most appropriate initial action when a nurse observes signs of phlebitis at an IV site is to remove the IV catheter. Phlebitis is an inflammatory response often caused by irritation of the vein, which can be exacerbated by the presence of the catheter. By removing the catheter, the nurse can prevent further irritation and potential complications from occurring. This action also ensures patient comfort and safety, reducing the risk of the condition worsening. Once the catheter is removed, the nurse can then take additional measures, such as assessing the site for further complications, documenting the findings, and potentially applying warm compresses to alleviate discomfort. Notifying the healthcare provider is also a critical step but typically occurs after assessing the immediate needs by removing the causative element—the IV catheter itself. Slowing the IV infusion rate may provide temporary relief, but it does not address the underlying issue of phlebitis, which necessitates catheter removal. Thus, removing the catheter is the foundational response that prioritizes patient safety and manages the condition effectively.

The most appropriate initial action when a nurse observes signs of phlebitis at an IV site is to remove the IV catheter. Phlebitis is an inflammatory response often caused by irritation of the vein, which can be exacerbated by the presence of the catheter. By removing the catheter, the nurse can prevent further irritation and potential complications from occurring. This action also ensures patient comfort and safety, reducing the risk of the condition worsening.

Once the catheter is removed, the nurse can then take additional measures, such as assessing the site for further complications, documenting the findings, and potentially applying warm compresses to alleviate discomfort. Notifying the healthcare provider is also a critical step but typically occurs after assessing the immediate needs by removing the causative element—the IV catheter itself.

Slowing the IV infusion rate may provide temporary relief, but it does not address the underlying issue of phlebitis, which necessitates catheter removal. Thus, removing the catheter is the foundational response that prioritizes patient safety and manages the condition effectively.