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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 IV.
C. Document in the nurse’s notes and notify the physician after redressing the site.
D. Clean the site well and redress.
Correct Answer: C
Explanation/Reference:
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.
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