Nurse notes redness, cracks, and blisters on the skin around a client's intravenous site. Which action should the nurse take first?
A. Administer diphenhydramine.
B. Remove transparent adhesive dressing.
C. Document findings in medical record.
D. Ask about previous reactions after eating kiwi.
Answer (2)
The nurse's first action should be to remove the transparent adhesive dressing from the IV site to address the skin reactions. This helps prevent further irritation and allows for proper assessment. Subsequent actions like documenting findings and considering medication can follow after the initial intervention. ;
The nurse's first action should be to remove the transparent adhesive dressing from the IV site to assess the area and prevent further irritation. After this, the nurse can document the findings and consider other interventions appropriately. Therefore, the correct choice is Option B: Remove transparent adhesive dressing.
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