On the infiltration scale for assessing a peripheral intravenous (IV) site, what grade would the nurse document when the assessment indicates the skin is blanched with 4.5 cm of edema, and the area is cool to touch?
a. 1
b. 2
c. 3
d. 4
B
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A A grade of 1 on the infiltration scale would indicate blanched skin, edema 2.5 cm in any direction, and the area cool to touch.
B A grade of 2 on the infiltration scale would indicate blanched skin, edema 2.5 to 15.2 cm in any direction, and the area cool to touch.
C A grade of 3 on the infiltration scale would indicate blanched, translucent skin, gross edema 15.2 cm in any direction, cool to touch, mild to moderate pain, and possible numbness.
D A grade of 4 on the infiltration scale would indicate skin that is blanched, translucent, tight and leaking, with gross deep pitting edema, circulatory impairment, moderate to severe pain, and infiltration.
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