A nurse is providing a handoff report to the oncoming shift nurse. Which of the following actions should the nurse take to ensure continuity of client care?

Rationale

A. Educate the client about potential adverse effects: Education is important but is not the immediate priority. Ensuring the client’s physiological stability takes precedence over providing information after an overdose. Education can follow once the client’s condition is assessed.

B. Complete an incident report: Completing an incident report is necessary for documentation and quality improvement, but it does not address the client’s immediate safety. Reporting comes after assessing and stabilizing the client.

C. Obtain the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s current physiological status. Monitoring for changes in blood pressure, heart rate, respiratory rate, and oxygen saturation helps identify early signs of adverse reactions and guides urgent interventions.

D. Notify the primary care provider: Notifying the provider is important to determine further medical management, but it should occur after assessing the client’s vital signs to provide accurate and current information about their condition. Immediate assessment ensures timely and appropriate provider guidance.

Rationale for Correct Choices

• Thrombophlebitis: The client has a red streak along the vein, palpable cord, warmth, tenderness, and pain at the IV site, which are classic signs of thrombophlebitis. This condition involves inflammation of the vein often accompanied by a thrombus.
• Infection: Presence of purulent drainage at the IV insertion site along with fever (38.6° C / 101.5° F) indicates a local IV-related infection. Infection can occur secondary to thrombophlebitis or as an independent complication of IV therapy.

Rationale for Incorrect Choices

• Extravasation: Extravasation involves leakage of vesicant medication into surrounding tissue causing tissue damage, which is not described here.
• Infiltration: Infiltration is the leakage of nonvesicant IV fluid into surrounding tissue, typically causing swelling, pallor, and coolness, not the red streak and purulent drainage seen in this client.
• Circulatory overload: Circulatory overload presents with dyspnea, hypertension, and edema, none of which are noted in this client.
• Phlebitis: Phlebitis involves vein inflammation and pain but does not usually include purulent drainage. Thrombophlebitis better describes the combination of inflammation with a palpable cord.