Difficulty: Medium
Average Score: 80%
Simulated
The nurse caring for a client receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? Select all that apply.
Correct answer
A,B,C,D,F
Rationale
Infiltration is the leakage of an IV solution into the extravascular tissue. Manifestations include slowing of the IV rate; burning, tenderness, or general discomfort at the insertion site; increasing edema in or around the catheter insertion site; complaints of skin tightness; blanching or coolness of the skin; and fluid leaking from the insertion site.