Difficulty: Medium
Average Score: 68%
Simulated
A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
Correct answer
C
Rationale
The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.