Evolve HESI Practice Exam

What action should the nurse take for a client receiving an IV cephalosporin antibiotic who shows signs of irritation at the infusion site?

1. Change the dressing

2. Slow down the infusion

3. Initiate an alternate site for IV infusion

4. Document the symptoms

The correct answer is: Initiate an alternate site for IV infusion

When a client receiving an IV cephalosporin antibiotic exhibits signs of irritation at the infusion site, the most appropriate action is to initiate an alternate site for IV infusion. This is crucial because irritation can indicate phlebitis, infiltration, or an allergic reaction to the medication or the IV materials. Continuing the infusion at an irritated site may exacerbate the underlying issue, leading to more significant complications such as tissue damage or systemic infection. Establishing a new IV site allows for the immediate management of the irritation. It ensures that the client continues to receive necessary medication while minimizing the risk of further complications. This course of action prioritizes patient safety and the integrity of the IV therapy. Changing the dressing may provide temporary reassurance but does not address the underlying cause of the irritation or resolve it. Slowing down the infusion may reduce discomfort, but it does not solve the problem of irritation at the existing site and may delay necessary treatment. Documenting the symptoms is essential for maintaining accurate medical records but should not be the primary action without first addressing the immediate concern of the infusion site irritation.