A nurse is assisting with the care of a client following a cerebral angiography. Which of the following actions should the nurse take?

A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.

A. Difficulty swallowing. While difficulty swallowing (dysphagia) can be associated with certain conditions, it is not a typical indicator of unrelieved pain in a client receiving a spinal epidural. This symptom may be related to neurological involvement or medication side effects and should be assessed further.
B. Constipation. Opioids used in conjunction with epidural anesthesia can contribute to constipation, but this is a side effect rather than a direct indicator of pain. Constipation can also result from reduced mobility or decreased fluid intake, so it should be managed appropriately but does not necessarily reflect uncontrolled pain.
C. Urinary retention. Epidural anesthesia can affect bladder function by impairing the sensation of fullness and the ability to void. While urinary retention is a common side effect of epidural use, it is not a direct sign of unrelieved pain. Monitoring for bladder distention and assessing for the need for catheterization is important.
D. Clenched teeth. Clenching the teeth is a physical manifestation of pain, often indicating discomfort and distress. Clients experiencing unrelieved pain may also exhibit other nonverbal cues such as grimacing, restlessness, or guarding. The nurse should assess pain using an appropriate scale and notify the provider if pain is not adequately controlled.