IV site complications

Question

An adult is receiving maintenance fluid through a peripheral IV. Review the note.

Step 1

Which current IV-site findings should the nurse report? Select all that apply.

1. ACool skin around the catheter✓ Correct

   This finding contributes to the concern described in the note.

2. BSwelling around the catheter✓ Correct

   This finding contributes to the concern described in the note.

3. CA request for a magazine✗ Incorrect

   This preference does not describe the clinical change.

4. DA request to sit upright✗ Incorrect

   This preference does not describe the clinical change.

5. EA preference for a pillow✗ Incorrect

   This preference does not describe the clinical change.

Rationale. Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. These preferences are not signs of a site complication.

Step 2

Which interpretation fits the current site?

1. APossible infiltration✓ Correct

   Coolness and swelling at an IV site can indicate infiltration.

2. BA definite bloodstream infection✗ Incorrect

   The site findings support concern about infiltration but do not establish these alternatives.

3. CAn uncomplicated infusion site✗ Incorrect

   The site findings support concern about infiltration but do not establish these alternatives.

4. DA confirmed allergic blood reaction✗ Incorrect

   The site findings support concern about infiltration but do not establish these alternatives.

Rationale. Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. The site findings support concern about infiltration but do not establish these alternatives.

Step 3

Which concern should the nurse report about the earlier site?

1. APossible inflammation of the vein✓ Correct

   Redness and tenderness along a vein can occur with phlebitis, which is inflammation of the vein.

2. BA blood product reaction✗ Incorrect

   Redness and tenderness along the vein warrant attention for phlebitis.

3. CA medication rash on the trunk✗ Incorrect

   Redness and tenderness along the vein warrant attention for phlebitis.

4. DA normal sign of IV function✗ Incorrect

   Redness and tenderness along the vein warrant attention for phlebitis.

Rationale. Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. Redness and tenderness along the vein warrant attention for phlebitis.

Step 4

What action is appropriate for the current site under facility policy?

1. AStop using the affected site and notify the provider✓ Correct

   Suspected infiltration calls for discontinuing the site under facility policy; reporting the concern supports further care.

2. BContinue fluids through the swollen site✗ Incorrect

   Using a site with suspected infiltration can add fluid to the surrounding tissue.

3. CIncrease the rate through the swollen site✗ Incorrect

   Using a site with suspected infiltration can add fluid to the surrounding tissue.

4. DIgnore the site until the bag is empty✗ Incorrect

   Using a site with suspected infiltration can add fluid to the surrounding tissue.

Rationale. Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. Using a site with suspected infiltration can add fluid to the surrounding tissue.

Step 5

The nurse finds the current site cool and swollen while fluid is infusing. What should the nurse do?

1. AStop the infusion at that site and report it✓ Correct

   Coolness and swelling can indicate infiltration, for which the affected site should be discontinued under facility policy.

2. BFlush the site to test it while continuing fluids✗ Incorrect

   The affected site should not continue to receive fluid.

3. CCover the site and continue the infusion✗ Incorrect

   The affected site should not continue to receive fluid.

4. DWait until the next scheduled check before reporting✗ Incorrect

   Suspected infiltration calls for action under facility policy rather than delaying attention until a later check.

Rationale. Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. The affected site should not continue to receive fluid.

Step 6

Which observation after the site is discontinued suggests local improvement?

1. AThe swelling and discomfort decrease✓ Correct

   Swelling and pain can accompany infiltration, so a decrease in these findings suggests local improvement.

2. BThe area becomes more swollen✗ Incorrect

   Increasing local changes require further attention.

3. CPain increases at the site✗ Incorrect

   Increasing local changes require further attention.

4. DRedness extends along the vein✗ Incorrect

   Increasing local changes require further attention.

Rationale. Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. Increasing local changes require further attention.

Rationale

Cool swelling near an IV suggests fluid has escaped into tissue; redness and tenderness along a vein suggest inflammation. The nurse reports concerning changes and follows the prescribed plan while monitoring the client.