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Difficulty: EasyPharmacological and Parenteral Therapies

A nurse is preparing to discontinue a client's peripheral intravenous (IV) catheter. Place the following steps in the correct chronological order from first to last.

  1. 1Perform hand hygiene and don clean gloves.
  2. 2Clamp the IV tubing and carefully remove the securement dressing.
  3. 3Withdraw the catheter smoothly and horizontally from the vein.
  4. 4Apply firm, continuous pressure over the insertion site with a sterile gauze pad.
  5. 5Inspect the removed catheter tip to ensure it is completely intact.

Answer

The correct sequence is: perform hand hygiene and don gloves, clamp tubing and remove dressing, withdraw the catheter, apply firm pressure, and finally inspect the catheter tip.
The correct sequence ensures patient safety, infection control, and proper hemostasis during the discontinuation of a peripheral IV line. Standard precautions must be taken first. Then, the site is freed from securement devices so the catheter can be withdrawn smoothly without causing trauma. Once removed, immediate direct pressure prevents bleeding and hematoma formation. Finally, inspecting the catheter ensures that no fragments have broken off into the patient's circulatory system.

Step-by-Step Solution

1
Initiate standard precautions by performing hand hygiene and applying gloves.
The nurse is protected, and the patient is safe from contamination.
Infection control is the foundational first step for any procedure involving potential blood exposure.
2
Stop the flow of fluids by clamping the tubing and remove the adhesive dressing.
The IV catheter is no longer secured to the patient's skin.
The dressing must be removed before the catheter can be physically withdrawn.
3
Pull the catheter out of the vein in a smooth, straight motion.
The catheter is completely removed from the patient's arm.
Removing it parallel to the skin prevents injury to the vein wall.
4
Immediately place a sterile gauze pad over the site and hold firm pressure.
Bleeding stops and a clot begins to form.
Direct pressure is required to achieve hemostasis and prevent a hematoma.
5
Look closely at the tip of the removed IV catheter.
The nurse confirms the entire catheter was removed.
A missing tip indicates a catheter embolus, which is a medical emergency requiring immediate intervention.

Key Concept

Discontinuation of a Peripheral Intravenous (IV) Catheter
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Topics

Pharmacological and Parenteral Therapies

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