Question

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

a) Warmth and redness at the site
b) Pallor and coolness at the site
c) Pain at the site during infusion
d) Pitting edema at the site

Answer 1

The nurse should recognize pallor and coolness at the IV site as signs of infiltration, which is different from inflammation that involves redness, warmth, and swelling.

Step-by-step explanation:

The nurse should identify pallor and coolness at the IV site as indicators of infiltration. Unlike the signs of inflammation which include redness, warmth, and pain, infiltration at an IV site typically presents with the site being pale and cooler than the surrounding tissue. This condition occurs when IV fluid inadvertently enters the surrounding tissue rather than the vein. Infiltration can also lead to pitting edema at the site, another sign the nurse should check for. It is important to differentiate between inflammation, which can be characterized by localized redness, heat, and swelling due to infection or injury, and infiltration which requires immediate response to prevent further tissue damage