For a client receiving IV fluids, what finding indicates the need for immediate intervention by the nurse?

The presence of sudden swelling around the IV site is a critical finding that signals the need for immediate intervention by the nurse. This swelling could indicate a number of potentially serious issues, including infiltration, where IV fluids are leaking into the surrounding tissues instead of remaining within the vein. Infiltration can lead to discomfort, tissue damage, or even complications such as compartment syndrome, which is an increase in pressure within a closed muscle compartment that can lead to nerve and muscle damage.

In contrast, a warm and dry IV site might suggest normal functioning of the IV without complications, and well-infusing fluids indicate that the IV access is likely patent and functioning correctly. A lower blood pressure could be concerning, often indicating a need for further assessment or intervention, but it does not necessarily relate directly to the IV site itself in the immediate context of needing action regarding the IV. Sudden swelling, however, poses an immediate risk to the integrity of venous access and patient safety, warranting prompt assessment and corrective measures.