A patient is receiving intravenous (IV) chemotherapy through a peripheral line. Which IV site assessment finding indicates to the nurse that the IV access needs to be discontinued?
a. Bruising at the insertion site
b. Coolness of the skin below the site
c. Tissue swelling above and below the site
d. Wetness of the dressing over the access site
C
Swelling of the tissue above and below the site is an indication of fluid leakage from the vein into the tissues (infiltration). Even if the infusion did not contain any chemotherapy drugs, the infusion needs to be discontinued. Bruising is an indication of tissue trauma but not infiltration or extravasation. Coolness of the skin below the site is not specific to infiltration or extravasation. Dressing wetness indicates an external leak.
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