Difficulty: Medium
Average Score: 68%
Simulated
The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?
Correct answer
A
Rationale
The correct action for the nurse to take first when suspecting infiltration of an IV solution is to stop the infusion immediately (Choice A). This is crucial to prevent further harm to the client. Continuing the infusion can lead to tissue damage, pain, and potential complications. By stopping the infusion, the nurse can evaluate the site for signs of infiltration and take appropriate actions. Documenting the findings (Choice B) is important but should come after addressing the immediate issue. Flushing the catheter with normal saline (Choice C) may worsen the infiltration. Removing the catheter and applying pressure (Choice D) should only be done after stopping the infusion and assessing the situation.