ATI LPN comprehensive predictor 2023 retake proctored exam
A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?
Explanation & Rationale
A. Erythema is a sign of infection or irritation, not fluid infiltration. Fluid infiltration typically does not cause redness or inflammation. B. Edema is correct. Fluid infiltration occurs when the IV catheter becomes displaced and the fluid leaks into the surrounding tissue, causing swelling (edema. at the insertion site. C. Blood would suggest either an accidental dislodging of the catheter or a complication such as hematoma formation, but it is not a sign of fluid infiltration. D. Pruritus (itching) is typically associated with an allergic reaction, not fluid infiltration.
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