Which of the following actions would be appropriate to implement based on this finding?

While changing the dressing on a client’s central line, the nurse notices redness and warmth at the needle insertion site.

Which of the following actions would be appropriate to implement based on this finding?
A . Discontinue the central line.
B . Begin a peripheral I
D . Document in the nurse’s notes and notify the physician after redressing the site.
E .  Clean the site well and redress.

View Answer

Answer: C

Explanation:

(A) The nurse may never discontinue a central line without a physician’s order.

(B) The nurse may never initiate a peripheral IV without a physician’s order except in an emergency situation.

(C) The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.

(D) Besides cleaning and redressing, the nurse should always document the findings.