The nurse assesses a patient's right hand IV site to be infiltrated. Appropriate nursing actions include (Select all that apply.)
a. stopping the infusion.
b. attempting to aspirate the medication.
c. elevating the affected limb.
d. checking capillary refill.
e. removing the catheter as directed by policy.
ANS: A, C, D, E
For an infiltration, stop the infusion. Elevate the affected limb. Assess for circulatory compromise; check capillary refill and pulses proximal and distal to the area of infiltration. If the infiltration is caused by an IV solution, remove the catheter as directed by policy. For extravasation, attempts may be made to aspirate the medication.
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