A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the priority actions should the nurse take?

Rationale:

A. To remove air from the tubing is correct. Priming an IV line involves filling the tubing with IV fluid before connecting it to the patient to eliminate all air bubbles. This is crucial because air entering the bloodstream can cause an air embolism, which is potentially life-threatening, especially if it reaches the heart or lungs. Air embolism can lead to chest pain, dyspnea, hypotension, or cardiovascular collapse. Priming ensures that fluid flows continuously and safely into the vein.

B. To warm the fluid is incorrect because priming does not warm IV fluids. If warmed fluids are required for patient comfort or therapeutic reasons (e.g., hypothermic patients or rapid transfusions), a fluid warmer or other warming device must be used. Priming is strictly a safety step to remove air, not to adjust temperature.

C. To ensure sterility is incorrect because priming does not sterilize the tubing or fluid. Sterility is maintained by aseptic technique during preparation, handling, and connection of the IV. Priming does not replace proper infection control measures such as hand hygiene, using sterile gloves, or disinfecting ports.

D. To improve flow rate is incorrect because while priming allows fluid to flow freely, the actual flow rate is determined by the IV pump or the roller clamp. Priming ensures safety and patency, not the speed of infusion.

Rationale:

A. Document findings is incorrect because while documentation is essential in nursing practice, it is not the immediate priority when a client is experiencing symptoms that could indicate a serious reaction. Recording information without first addressing the potential problem delays interventions that may prevent harm. Documentation should always follow assessment and stabilization.

B. Reassure the client this is expected is incorrect because telling the client that dizziness and nausea are normal could downplay potentially serious signs. These symptoms could indicate hypotension, an allergic reaction, rapid infusion, or fluid/electrolyte imbalance. Reassurance without assessment puts the patient at risk and may delay emergency intervention if needed.

C. Administer an antiemetic is incorrect because giving medication before assessing the patient could mask important clinical signs. While an antiemetic might relieve nausea, it does not address the underlying cause, which could be hypotension, a medication reaction, or fluid overload. Administering treatment without assessment violates patient safety principles.

D. Stop the infusion and assess vital signs is correct. Stopping the infusion prevents further exposure to the medication that may be causing the reaction, and assessing vital signs helps determine if the patient is experiencing hypotension, tachycardia, or other signs of adverse reaction. After this assessment, the nurse can notify the provider, provide supportive care, and document appropriately.