Difficulty: Medium
Average Score: 65%
Simulated
Passage / Scenario
A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter.Which of the following observations at the IV site should the nurse identify as signs of infiltration?
Correct answer
A
Rationale
The correct answer is A: Skin blanching. Blanching occurs when the blood flow is compromised due to infiltration, causing the skin to appear pale or white when pressure is applied. This indicates that the IV fluid is not entering the vein properly and is leaking into the surrounding tissues. Bleeding (choice B) is not a typical sign of infiltration but rather indicates a puncture site issue. Purulent exudate (choice C) suggests infection, not infiltration. Warmth (choice D) is more indicative of phlebitis, inflammation of the vein. Other choices are not relevant to infiltration assessment. In conclusion, skin blanching is the key indicator of infiltration due to compromised blood flow, distinguishing it from other complications.