NCLEX-RNPharmacological and Parenteral TherapiesMedium
A client is receiving a continuous intravenous infusion of 0.9% Normal Saline at 100 mL/hour. The nurse assesses the client's IV site and notes swelling, coolness, and pallor above the insertion site. The client reports discomfort. What is the most appropriate initial nursing action?
- AElevate the extremity and notify the healthcare provider.
- BAspirate for blood return and flush with 5 mL of saline.
- CSlow the infusion rate and apply a warm compress.
- DDiscontinue the infusion and remove the catheter.
Show answer & explanationAnswer & explanation
Correct answer: D. Discontinue the infusion and remove the catheter.
The symptoms of swelling, coolness, pallor, and discomfort above the insertion site are classic signs of IV infiltration. The most appropriate initial nursing action for infiltration is to discontinue the infusion and remove the catheter to prevent further tissue damage.
Why the other options are wrong
- A. Elevating the extremity and notifying the provider are secondary actions; the priority is to stop the infiltration.
- B. Aspirating for blood return and flushing are done to assess patency, but with clear signs of infiltration, these actions are inappropriate and could worsen the infiltration.
- C. Slowing the infusion and applying a warm compress may be done after discontinuing, but not as the initial action when infiltration is present.
IV Infiltration Signs & Action
IV infiltration occurs when non-vesicant fluid leaks into the extravascular tissue around the injection site, causing swelling, coolness, pallor, and discomfort. The immediate action is to stop the infusion and remove the catheter.
- Symptoms: swelling, pallor, coolness, pain at site.
- Possible causes: dislodged catheter, punctured vein.
- Action: Discontinue IV, remove catheter, elevate extremity.
- Apply warm or cold compress based on solution type and facility policy.
Memory trick: STOP the Leak, TAKE it OUT, TREAT the site.