The nurse is caring for a client with an IV line continuously infusing solution containing dextrose and water
The client complains of a burning pain along the course of the vein, and the nurse assesses the site to find redness, warmth, and mild swelling at the site. Based on these assessment findings, which term will the nurse use when documenting these findings?
1. Phlebitis at the IV insertion site
2. IV infiltrate
3. Extravasated vesicant drug
4. Extravasation
Correct Answer: 1
Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client's site is red and warm, not cool and pale, so it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation.
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