A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?
Explanation & Rationale
A. Slow the infusion rate is not an appropriate action when infiltration is noted. The infusion should be stopped immediately to prevent further leakage of fluid into the surrounding tissues. B. Flush the IV catheter is not recommended in the case of infiltration, as it can cause more fluid to enter the surrounding tissues and worsen the infiltration. C. Apply pressure to the IV site is not appropriate for managing infiltration. Applying pressure can cause further damage to the tissues and increase discomfort. D. Elevate the extremity is the correct action to take. Elevating the affected limb can help reduce swelling and promote the reabsorption of the infiltrated fluid. Additionally, the IV catheter should be removed, and a new IV site should be selected.