When a nurse assesses a client with a hematoma at an IV site, what should be the nurse's initial response?

In the situation where a nurse assesses a client with a hematoma at an IV site, the most appropriate initial response would be to remove the IV catheter. This action is critical because leaving the catheter in place could lead to further complications such as increased pain, risk of infection, or additional bleeding, particularly if the hematoma is expanding or the site is becoming more inflamed.

Removing the IV catheter addresses the immediate concern of the hematoma and allows for the assessment of the site to determine the extent of the damage. It also provides an opportunity to assess the need for alternative IV access if necessary. Following the removal, appropriate measures such as elevation of the limb, the application of ice, or monitoring for changes can be considered to manage the hematoma effectively.

In this context, other options, such as applying warm, moist compresses or notifying the healthcare provider, may also be important steps, but they would typically come after the initial action of removing the IV catheter to prevent further injury or complications related to the hematoma.