A nurse is caring for a client who has metabolic acidosis due to diabetic ketoacidosis (DKA) Which of the following manifestations should the nurse monitor?

Choice A reason: Shaving the hair around the insertion site is not recommended because it can cause skin irritation and increase the risk of infection.

Choice B reason:

Obtaining informed consent from the patient is important, but it is not a step that the nurse should perform before inserting the catheter. Informed consent should be obtained by the physician or advanced practice nurse who will perform the procedure.

Choice C reason:

Administering prophylactic antibiotics to the patient is not a routine practice for central venous catheter insertion. Antibiotics may be indicated for patients with certain risk factors, such as immunosuppression, but they should be prescribed by the physician or advanced practice nurse.

Choice D reason:

Placing the patient in Trendelenburg position is an important step that the nurse should perform before inserting the catheter. This position helps to distend the jugular vein and reduce the risk of air embolism during catheter insertion.

Choice A reason:

Applying warm compresses to the site and elevating the arm may help to reduce pain and swelling, but they do not address the underlying cause of the problem, which is likely infiltration or phlebitis of the IV site. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing edema, coolness, and pallor. Phlebitis occurs when the vein becomes inflamed, causing pain, erythema, and warmth. Both conditions require immediate removal of the IV catheter and restarting a new IV in another site.

Choice B reason:

Slowing down the infusion rate and documenting the findings may be appropriate actions after removing the IV catheter and starting a new IV in another site, but they are not sufficient to resolve the problem. Slowing down the infusion rate may reduce the discomfort and prevent further complications, but it does not stop the leakage or inflammation of the IV site. Documenting the findings is important for legal and quality improvement purposes, but it does not provide any intervention for the patient's pain or risk of infection.

Choice C reason:

Stopping the infusion, removing the IV catheter, and starting a new IV in another site is the most appropriate action by the nurse. This action prevents further damage to the tissue or vein, reduces the risk of infection, and restores adequate IV access for fluid and medication administration. The nurse should also apply a sterile dressing to the affected site, monitor for signs of infection or complications, and notify the physician if needed. This is the correct answer.

Choice D reason:

Notifying the physician and obtaining an order for an antihistamine is not an appropriate action by the nurse. This action implies that the patient is having an allergic reaction to the IV fluid or medication, which is not supported by the assessment findings. An antihistamine may help to reduce itching or swelling, but it does not address the cause of the pain or prevent further tissue or vein damage. The nurse should notify the physician after removing the IV catheter and starting a new IV in another site, and only if there are signs of infection or complications that require medical intervention.