NCLEX-PN® ExaminationSafety and Infection ControlEasy
An LPN is assisting with the care of a client who is receiving intravenous (IV) fluids. The LPN notes swelling, coolness, and pain at the IV insertion site. Which action should the LPN take FIRST?
- ANotify the registered nurse (RN).
- BApply a warm compress to the site.
- CElevate the affected extremity.
- 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, and pain at the IV site are indicative of infiltration. The primary action for infiltration is to discontinue the infusion and remove the catheter to prevent further fluid leakage into the surrounding tissue.
Why the other options are wrong
- A. Notifying the RN is important, but the immediate safety action is to stop the infiltration by discontinuing the IV.
- B. Applying a warm compress might be done after discontinuing the IV, but not as the first action.
- C. Elevating the extremity might help reduce swelling but does not address the underlying problem of infiltration.
IV Infiltration Management
Infiltration occurs when IV fluid leaks into the surrounding subcutaneous tissue instead of entering the vein. It presents as swelling, coolness, and pain at the insertion site.
- Immediate action is to stop the infusion and remove the catheter.
- Can cause discomfort and potential tissue damage.
- Often requires starting a new IV in a different location.
Memory trick: Stop the Drip, then Strip the Trip.