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.
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.