The nurse assesses the client's IV site and determines that it has infiltrated. The nurse's best response is to:
a. call the health care provider
b. immediately stop the IV infusion.
c. apply a cold compress and slow the rate of infusion.
d. complete an incident report.
ANS: B
Feedback
A Incorrect: This is not the nurse's first action.
B Correct: The nurse should immediately stop the infusion, so that no more fluid flows into the tissues surrounding the vein to prevent further tissue trauma.
C Incorrect: After stopping the infusion, the nurse should follow the protocol of the institution regarding how to treat the site.
D Incorrect: An incident or variance report generally is not initiated unless serious tissue damage has occurred.
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