A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

Choice A reason: Documenting infiltration records the event but does not address the immediate issue. Edema and coolness suggest fluid leakage into tissues, which can cause damage if not stopped. Documentation is secondary to halting the infusion, as it only logs data without mitigating the ongoing extravasation harming the client’s tissue integrity.

Choice B reason: Applying a warm compress may increase blood flow and reduce swelling later, but it does not stop the fluid leakage causing the edema. The priority is to cease the infusion to prevent further tissue damage from ongoing infiltration, making this a subsequent action rather than the first step.

Choice C reason: Elevating the arm can help reduce swelling by aiding venous return, but it does not address the source of the problem—fluid leaking from the IV. Stopping the infusion first prevents additional extravasation, as elevation alone cannot halt the ongoing tissue damage caused by the continuous fluid administration.

Choice D reason: Stopping the infusion is the priority because edema and coolness indicate infiltration, where IV fluid leaks into surrounding tissues. Ceasing the flow prevents further damage, such as tissue necrosis or nerve injury, which can occur if fluid continues to accumulate, making this the critical first step in management.

Choice A reason: Applying suction while inserting risks trauma to nasal mucosa, as continuous pressure can tear delicate tissues or cause bleeding. Proper technique involves inserting without suction, then applying it on withdrawal to safely remove secretions, minimizing injury and ensuring effective clearance without damaging the airway lining.

Choice B reason: Intermittent suction for 30 seconds exceeds safe limits; guidelines recommend 10-15 seconds to avoid hypoxia. Prolonged suction depletes oxygen in the airway, especially in nasopharyngeal suctioning, where ventilation is obstructed, risking respiratory distress or cardiac complications in an adult client with compromised breathing.

Choice C reason: Inserting the catheter 10 cm (4 in) is too shallow for nasopharyngeal suctioning in adults, where 16-20 cm reaches the pharynx. Insufficient depth fails to clear secretions effectively, leaving mucus in lower airways, potentially worsening obstruction or infection, as the catheter must target the secretion source accurately.

Choice D reason: Waiting 1 minute between attempts allows oxygen levels to stabilize, preventing hypoxia during nasopharyngeal suctioning. This interval ensures the client reoxygenates after airway occlusion, reducing risks of desaturation or arrhythmia, aligning with safe practice to maintain respiratory stability while clearing mucus effectively in adults.