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) Redness and warmth at the site
b) Coolness and pallor at the site
c) Formation of a blood clot
d) Clear, straw-colored urine output

Answer 1

Clear, straw-colored urine output is not an indication of infiltration at an IV site. Infiltration is a complication that occurs when fluid from an IV site infiltrates into the surrounding tissue instead of going into the bloodstream.

Step-by-step explanation:

Infiltration is a complication that can occur when fluid from an intravenous (IV) site infiltrates into the surrounding tissue instead of going into the bloodstream. This can happen when the IV catheter becomes dislodged or punctures a vein. In the given scenario, clear, straw-colored urine output is not an indication of infiltration.

When infiltration occurs, the IV site may show signs such as swelling, coolness or coldness to the touch, blanching, and discomfort or pain. The fluid that infiltrates into the tissue may cause localized tissue damage and can interfere with the delivery of medications or fluids.

Therefore, the nurse should not consider clear, straw-colored urine output as an indicator of infiltration. Instead, the nurse should assess the IV site for other signs and symptoms of infiltration.