Difficulty: Medium
Average Score: 64%
Simulated
Which of the following actions should the nurse take when observing infiltration of fluid into the tissue surrounding an IV insertion site?
Correct answer
C
Rationale
The correct answer is C: Elevate the extremity. Elevating the extremity helps to reduce swelling and minimize further infiltration of fluid into the surrounding tissue. By elevating the extremity, gravity assists in draining the fluid away from the IV site. This action helps to prevent tissue damage and potential complications.
Incorrect choices:
A: Flushing the IV catheter will not address the infiltration and may worsen the situation.
B: Applying pressure to the IV site can further damage the tissue and exacerbate the infiltration.
D: Slowing the infusion rate may not prevent further infiltration and does not address the existing issue effectively.
Incorrect choices:
A: Flushing the IV catheter will not address the infiltration and may worsen the situation.
B: Applying pressure to the IV site can further damage the tissue and exacerbate the infiltration.
D: Slowing the infusion rate may not prevent further infiltration and does not address the existing issue effectively.