The nurse is preparing to insert a central venous catheter into a patient's right internal jugular vein using ultrasound guidance. What is an important step that the nurse should perform before inserting the catheter?

Choice A reason:

Applying warm compresses to the site and elevating the arm may help to reduce pain and swelling, but they do not address the underlying cause of the problem, which is likely infiltration or phlebitis of the IV site. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing edema, coolness, and pallor. Phlebitis occurs when the vein becomes inflamed, causing pain, erythema, and warmth. Both conditions require immediate removal of the IV catheter and restarting a new IV in another site.

Choice B reason:

Slowing down the infusion rate and documenting the findings may be appropriate actions after removing the IV catheter and starting a new IV in another site, but they are not sufficient to resolve the problem. Slowing down the infusion rate may reduce the discomfort and prevent further complications, but it does not stop the leakage or inflammation of the IV site. Documenting the findings is important for legal and quality improvement purposes, but it does not provide any intervention for the patient's pain or risk of infection.

Choice C reason:

Stopping the infusion, removing the IV catheter, and starting a new IV in another site is the most appropriate action by the nurse. This action prevents further damage to the tissue or vein, reduces the risk of infection, and restores adequate IV access for fluid and medication administration. The nurse should also apply a sterile dressing to the affected site, monitor for signs of infection or complications, and notify the physician if needed. This is the correct answer.

Choice D reason:

Notifying the physician and obtaining an order for an antihistamine is not an appropriate action by the nurse. This action implies that the patient is having an allergic reaction to the IV fluid or medication, which is not supported by the assessment findings. An antihistamine may help to reduce itching or swelling, but it does not address the cause of the pain or prevent further tissue or vein damage. The nurse should notify the physician after removing the IV catheter and starting a new IV in another site, and only if there are signs of infection or complications that require medical intervention.

Choice A reason:

Administer the solution via a central line. This is correct because 3% sodium chloride solution is a hypertonic solution that can cause phlebitis and tissue damage if infused peripherally. A central line can deliver the solution more safely and effectively.

Choice B reason:

Monitor serum sodium levels every 4 hours. This is correct because serum sodium levels can indicate the effectiveness of the therapy and the risk of complications such as hypernatremia or cerebral edema. The normal range of serum sodium is 135 to 145 mEq/L.

Choice C reason:

Titrate the infusion rate according to urine output. This is incorrect because the infusion rate of 3% sodium chloride solution should be titrated according to serum sodium levels, not urine output. Urine output can be affected by other factors such as renal function, fluid intake, and diuretics.

Choice D reason:

Assess for signs of fluid overload. This is correct because 3% sodium chloride solution can cause fluid shifts from the intracellular and interstitial spaces to the intravascular space, leading to fluid overload. Signs of fluid overload include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

Choice E reason:

Keep an accurate intake and output record. This is correct because intake and output records can help monitor the fluid balance and identify any excesses or deficits. Intake includes oral fluids, intravenous fluids, tube feedings, and blood products. Output includes urine, stool, vomitus, drainage, and insensible losses.