A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness. The nurse suspects that the
a. IV has infiltrated.
b. IV has caused phlebitis.
c. Fluid is infusing too quickly.
d. Patient is allergic to the fluid.
ANS: C
The infusion may be flowing faster than the vein can handle, causing discomfort. The nurse should slow down the infusion. Infiltration results in skin that is blanched, cool, and edematous around the IV insertion site. Pain, warmth, erythema, and a palpable venous cord are all symp-toms of phlebitis. Allergic response to the fluid could involve a combination of itching, flushing, hypotension, and dyspnea, depending on the severity.
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