Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.)
a. Edema of the extremity near the insertion site
b. Reddish streak proximal to the insertion site
c. Skin discolored or pale in appearance
d. Pain and warmth at the insertion site
e. Palpable venous cord
f. Skin cool to the touch
ANS: A, C, F
Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.
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