A nurse is reviewing a client's laboratory results before administering furosemide 40 mg IV bolus. For which of the following values should the nurse withhold the medication and contact the provider?

Choice A Reason:
Extravasation is incorrect. This occurs when the intravenous fluid leaks into the surrounding tissue rather than remaining within the vein. It may cause swelling, pain, and potential tissue damage due to the infused solution's irritant effects.
Choice B Reason:
Phlebitis is correct. Phlebitis refers to the inflammation of a vein often characterized by redness, warmth, swelling, and tenderness along the course of the vein. It can occur due to various reasons, including irritation from the IV catheter, chemical irritation from the infused solution, or infection.
Choice C Reason:
Infiltration is incorrect. Infiltration refers to the inadvertent leakage of the infused fluid into the surrounding tissues. It may cause swelling and discomfort but doesn't typically present with redness and inflammation along the vein.
Choice D Reason:
Venous spasm is incorrect. Venous spasm involves the involuntary contraction of the vein, which can occur in response to irritation or trauma. It may cause temporary difficulty in IV access but does not usually present with redness and inflammation along the vein as the primary signs.

Choice A Reason:
. "I will check the client's INR before administering the heparin." Is incorrect. Checking the client's INR (International Normalized Ratio) is essential, but it's more applicable for monitoring anticoagulants like warfarin, not heparin. Heparin's effect is typically monitored via activated partial thromboplastin time (aPTT) or anti-Xa levels, not INR.
Choice B Reason:
"I will aspirate before administering the heparin." Is incorrect. Aspirating before administering heparin injections is not necessary because the medication is given subcutaneously or intravenously and not into a blood vessel.
Choice C Reason:
"I will massage the site after injecting the heparin." Is incorrect. Massaging the site after injecting heparin could increase the risk of bruising or hematoma formation at the injection site. It's generally advised to avoid massaging the area after a heparin injection to prevent tissue trauma.
Choice D Reason:
"I will apply pressure for 1 minute after the injection." Is correct. Applying pressure to the injection site for about a minute after administering heparin helps minimize the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in reducing bleeding at the injection site.