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    Ati Lpn Med Surg IV Therapy Proctored Exam

    A client has IV infiltration. What is the priority action?

    Explanation & Rationale

    Rationale: A. Applying a warm compress is an appropriate intervention after stopping the IV to help promote absorption of the infiltrated fluid and relieve discomfort, but it is not the first or priority action. Warm compresses alone do not prevent further tissue damage if the IV remains in place. B. Slowing the infusion rate is inappropriate in the case of infiltration because continuing any flow of fluid into the tissue can worsen swelling, discomfort, and tissue damage. Stopping the infusion entirely is required first. C. Elevating the extremity can help reduce swelling after the IV has been discontinued and infiltration managed, but it is a secondary intervention. Elevation without stopping the IV does not address the root problem. D. Discontinuing the IV is the priority action. Infiltration occurs when IV fluid leaks into the surrounding tissue rather than the vein. Continuing the infusion can worsen tissue injury, pain, and edema. Stopping the IV immediately prevents further damage and allows for subsequent interventions, such as applying warm or cold compresses, elevating the extremity, and monitoring for complications.

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