Question

30) A nurse is monitoring a patient who is receiving fluids intravenously. Which clinical manifestations at the insertion site indicate that the IV has infiltrated? SELECT ALL THAT APPLY.

1. Redness
2. Swelling
3. Firmness
4. Coolness
5. Inflammation

Answer 1

The clinical manifestations that indicate IV infiltration at the insertion site include swelling, firmness, and coolness. Redness and inflammation may signify other issues like infection, but are not specific to infiltration.

Step-by-step explanation:

Clinical Indicators of IV Infiltration

When a nurse is monitoring a patient who is receiving fluids intravenously, there are certain clinical manifestations to look out for that may indicate IV infiltration. The presence of an infiltration can be identified if swelling, firmness, and coolness are observed at the insertion site. These manifestations suggest that the IV fluid is leaking into the surrounding tissue, rather than being delivered into the vein.

While redness and inflammation may indicate other issues such as infection or an immune response, they are not typically signs of infiltration. Instead, symptoms of an infiltrated IV include:

Swelling - an accumulation of fluid in the tissues around the IV site

Firmness - the area around the IV site may feel more firm due to the fluid build-up

Coolness - the skin around the IV site may be cooler, as the fluids are not being circulated via the bloodstream

Swelling, firmness, and coolness are the key indicators that a nursing professional should be aware of when assessing a patient for potential IV infiltration.