A nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing
The nurse interprets that which of the following complications has been experienced by the client? 1. Phlebitis
2. Infection
3. Infiltration
4. Thrombosis
3
Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcu-taneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to clamp the IV tubing, remove the catheter, and prepare to start a new IV line. The other three options are likely to be accompanied by warmth at the site, not coolness.
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