A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply
A) Swelling
B) Redness
C) Pallor
D) Warmth to touch
E) Pain
Ans: A, C, E
Feedback:
Infiltration is manifested by pain and by swelling around the infusion site which usually becomes cool to the touch. The area is also pale in color. Warmth and redness suggest phlebitis.
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