What should the nurse do upon noting that the patient's IV site is pale, cool, and edematous? (Select all that apply.)
a. Stop the infusion.
b. Elevate the extremity.
c. Start a new IV.
d. Flush the IV site.
A, B, C
Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate. The nurse should stop the infusion and should discontinue the IV, elevate the affected extremity, start a new IV if continued therapy is necessary, and document the degree of infiltration and nursing intervention. Flushing the IV site is not recommended.
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