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    Ati Lpn Med Surg Therapy Proctored Exam

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

    Explanation & Rationale

    Rationale: A. Discontinue the IV is correct because the first and most important action when infiltration occurs is to stop the IV infusion and remove the catheter. Continuing the infusion can increase tissue damage, swelling, and discomfort, especially if the fluid is irritating to the tissues. B. Slow the infusion rate is incorrect because slowing the infusion does not stop the fluid from leaking into the surrounding tissue. The IV must be removed to prevent further infiltration and potential tissue injury. C. Elevate the extremity after stopping the IV is incorrect as the first action because while elevation can help reduce swelling, it is secondary to discontinuing the IV, which addresses the root cause. D. Apply a warm compress is incorrect as the first step because compresses are only applied after the IV is discontinued to promote absorption of infiltrated fluid and relief of discomfort. Cold compresses may be used for certain types of infiltration depending on the fluid.

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