A nurse assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

A. Diarrhea and vomiting for 36 hours:

Diarrhea and vomiting can lead to metabolic acidosis due to loss of bicarbonate and increased hydrogen ion concentration in the blood. However, the ABG values provided indicate respiratory alkalosis (high pH and low PaCO2), which is not consistent with metabolic acidosis caused by diarrhea and vomiting. Therefore, this choice does not correlate with the ABG values.

B. Chronic obstructive pulmonary disease (COPD):

COPD is a respiratory condition characterized by airflow limitation and increased airway resistance. It can lead to respiratory acidosis due to retention of carbon dioxide (PaCO2 levels would be elevated). The ABG values in the scenario show respiratory alkalosis (low PaCO2), which is the opposite of what would be expected in COPD. Therefore, this choice does not correlate with the ABG values provided.

C. Anxiety-induced hyperventilation:

Anxiety-induced hyperventilation is a common cause of respiratory alkalosis. During hyperventilation, there is excessive elimination of carbon dioxide (PaCO2 levels decrease), leading to an increase in pH (alkalosis). The ABG values in the scenario show a high pH (7.48) and low PaCO2 (28 mm Hg), consistent with respiratory alkalosis seen in hyperventilation due to anxiety.

D. Diabetic ketoacidosis and chronic obstructive pulmonary disease (COPD):

Diabetic ketoacidosis (DKA) is a metabolic condition characterized by hyperglycemia, ketosis, and metabolic acidosis (low pH and low bicarbonate levels). COPD, as mentioned earlier, can lead to respiratory acidosis due to retained carbon dioxide. Neither of these conditions correlates with the ABG values provided, which show respiratory alkalosis (high pH and low PaCO2). Therefore, this choice does not correlate with the ABG values.

A. Stop the infusion of IV fluids:

This action may be appropriate if there are signs of infiltration or extravasation, where the IV fluid leaks into the surrounding tissue instead of entering the vein. Stopping the infusion can help prevent further tissue damage and assess the extent of the infiltration.

B. Apply cold compresses to the IV site:

Cold compresses can help reduce swelling and discomfort at the IV site. This action may be appropriate if there are signs of local inflammation or mild irritation at the insertion site.

C. Elevate the extremity on a pillow:

Elevating the extremity can help reduce swelling and promote venous return. This action is beneficial if there is edema or localized swelling above the IV site.

D. Flush the catheter with normal saline:

Flushing the catheter with normal saline is not typically the initial action in response to edema and tenderness above the IV site. Flushing is more commonly performed to ensure patency and proper functioning of the IV catheter.