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Provide continuous IV fluids is incorrect because a saline lock is specifically designed for intermittent use. Continuous IV therapy requires a standard IV line with a fluid bag and infusion pump, which delivers fluids at a constant rate. Using a saline lock in place of a continuous infusion would not maintain adequate fluid administration.

Increase medication absorption is incorrect because the saline lock does not affect how the medication is absorbed. It is simply a method for delivering IV medications directly into the bloodstream. Absorption occurs the same way whether administered through a saline lock or continuous IV.

Prevent phlebitis is incorrect because while proper flushing of a saline lock can reduce the risk of clot formation or catheter occlusion, it does not prevent phlebitis, which is inflammation of the vein due to mechanical irritation, chemical irritation from medications, or infection. Preventing phlebitis involves correct catheter insertion technique, appropriate catheter size, careful medication selection, and monitoring the insertion site.

Fluid volume overload is incorrect because it affects the whole circulatory system, not just the IV site. Signs include edema, hypertension, distended neck veins, dyspnea, and crackles in the lungs, not localized redness, warmth, or pain at the insertion site.

Infiltration is incorrect because infiltration occurs when non-vesicant IV fluid enters the surrounding tissue. It usually presents as cool skin, swelling, and pallor around the site, not warmth and redness.

Extravasation is incorrect because extravasation involves leakage of vesicant (tissue-damaging) medications into surrounding tissue, causing pain, swelling, and possible tissue necrosis. While some signs overlap, redness and warmth alone without tissue damage is more characteristic of phlebitis.

Massage the site vigorously is incorrect because vigorous massage can damage the vein, increase the risk of hematoma formation, and cause patient discomfort. Gentle handling is important to minimize trauma to the vein and surrounding tissue.

Remove catheter quickly and leave site uncovered is incorrect because leaving the site uncovered increases the risk of infection and does not control bleeding. Additionally, removing the catheter without applying pressure could result in a hematoma, delayed clotting, or continued bleeding, which may be dangerous in certain patients.

Apply heat immediately is incorrect because heat is not recommended after IV removal. Heat can increase local blood flow, which may worsen bleeding or hematoma formation. Cold compresses may sometimes be used to reduce swelling if a hematoma develops, but routine heat application is not part of standard post-IV care.

Cyanosis of the nail beds and pain along the vein is incorrect because cyanosis indicates poor oxygenation, not phlebitis. While pain along the vein may occur in phlebitis, cyanosis is not characteristic.

The client's skin is cool to the touch around the insertion site is incorrect because coolness and pallor are typical signs of infiltration, where IV fluid leaks into surrounding tissue, rather than inflammation of the vein.

Purulent drainage is noted at the catheter insertion site is incorrect because purulent drainage is a sign of infection at the insertion site. Phlebitis can become infected, but purulence specifically indicates local infection rather than simple vein inflammation.

Client reports coolness at IV site is incorrect because coolness indicates infiltration, where IV fluid leaks into the surrounding tissue. Other signs of infiltration include pallor, swelling, and discomfort at the site. This is a local complication of IV therapy, not a systemic adverse medication reaction. It requires removal of the catheter and monitoring of the site, but it does not indicate an allergic reaction.

Blood return in the catheter is incorrect because blood return (also called flashback) indicates that the catheter is correctly placed in the vein. This is a normal finding, not a complication or reaction. It demonstrates patency and proper placement for infusion, and therefore does not signify an adverse effect of the medication.

Mild discomfort at insertion is incorrect because minor pain or discomfort during IV insertion is expected due to needle penetration of the skin and vein. This is normal procedural discomfort, not an adverse reaction. Nurses should still monitor for signs of phlebitis, infiltration, or infection, but mild insertion pain alone does not indicate a systemic medication reaction.

Non-dominant forearm is incorrect because the non-dominant arm is preferred for IV insertion to minimize interference with the patient’s daily activities and reduce the risk of accidental dislodgement.

Upper extremity veins is incorrect because veins in the upper extremity are the preferred sites for peripheral IV access due to ease of access, visibility, and patient comfort.

A stable, palpable vein is incorrect because a palpable vein that does not roll and is stable is ideal for IV insertion. Such veins are less likely to infiltrate or dislodge and provide reliable access for infusion.

Slow the infusion rate is incorrect because slowing the infusion does not stop the fluid from leaking into the surrounding tissue. The IV must be removed to prevent further infiltration and potential tissue injury.

Elevate the extremity after stopping the IV is incorrect as the first action because while elevation can help reduce swelling, it is secondary to discontinuing the IV, which addresses the root cause.

Apply a warm compress is incorrect as the first step because compresses are only applied after the IV is discontinued to promote absorption of infiltrated fluid and relief of discomfort. Cold compresses may be used for certain types of infiltration depending on the fluid.

Ask the client which dose they usually take is incorrect because the client is not a reliable source for verifying IV medication dosages. Medication administration must always follow the provider’s order and MAR, not patient memory or preferences.

Administer it anyway because the order was placed yesterday is incorrect because administering a medication with a label that does not match the MAR is unsafe. Doing so could result in medication errors, overdosing, or underdosing, which can be harmful or fatal.

Change the MAR to match the label is incorrect because the MAR is a legal document reflecting the provider’s order. Altering it without proper verification is unsafe and violates policy.

Phlebitis is incorrect because phlebitis is localized inflammation of the vein and presents with redness, warmth, pain, and a palpable cord along the vein. It does not cause dyspnea or crackles in the lungs.

Air embolism is incorrect because an air embolism typically presents with sudden chest pain, hypotension, tachycardia, dyspnea, and sometimes a “mill wheel” murmur. While dyspnea occurs, crackles are not a characteristic finding of air embolism.

Infiltration is incorrect because infiltration involves leakage of IV fluid into surrounding tissue, leading to coolness, pallor, swelling, and discomfort at the insertion site, not pulmonary symptoms like dyspnea or crackles.

Eliminate the need for calculations is incorrect because even with an infusion pump, the nurse must program the correct rate and total volume, which requires accurate calculations. The pump assists with precision, but it does not remove the need for clinical judgment or math.

Increase client comfort is incorrect because although controlled infusion may be more comfortable than manual regulation, comfort is not the primary purpose of the pump. Its main role is safety and accuracy in fluid administration.

Reduce the risk of infection is incorrect because the pump itself does not prevent infection. Infection control depends on aseptic technique, proper catheter care, and site monitoring, not the use of an infusion pump.