IV Therapy Complications (Infiltration/Extravasation) - NCLEX Rn

1. Which finding most strongly suggests extravasation rather than simple infiltration?

   Blistering or skin necrosis near the IV site. Vesicant drugs cause direct tissue injury, progressing to blisters or necrosis, unlike nonvesicant infiltration which rarely leads to such severe damage.

2. Which compress is commonly used for many vesicant extravasations to limit spread?

   Cold compress (unless antidote/drug protocol specifies warm). Cold induces vasoconstriction, localizing vesicant and limiting its spread, unless protocol indicates warmth for dispersion.

3. Which option best defines IV extravasation?

   Leakage of vesicant medication into surrounding tissue. Extravasation happens when vesicant drugs leak from vein, potentially causing tissue irritation, blistering, or necrosis due to their caustic nature.

4. Which compress is typically used for most nonvesicant infiltrations to reduce swelling?

   Warm compress (unless drug-specific guidance differs). Warmth enhances circulation and absorption of nonvesicant fluid, aiding resolution of edema unless contraindicated by specific guidelines.

5. Identify the first nursing action when infiltration or extravasation is suspected.

   Stop the infusion immediately. Halting infusion prevents further leakage, minimizing tissue exposure and potential damage from continued fluid or drug extravasation.

6. What is the priority action regarding residual drug after suspected extravasation?

   Aspirate residual medication from the catheter if possible. Aspiration removes remaining vesicant from site, reducing tissue exposure and injury severity before catheter removal.

7. What is the correct action regarding the IV catheter after suspected extravasation?

   Remove the catheter after aspiration and per facility protocol. Catheter is retained briefly for aspiration or antidote, then removed to avoid further leakage per standard protocols.

8. Which option best defines IV infiltration?

   Leakage of nonvesicant IV fluid into surrounding tissue. Infiltration occurs when IV catheter dislodges, allowing non-irritating fluid to escape vein into tissue, causing local swelling without severe damage.

9. What skin color change is most consistent with IV infiltration?

   Pallor or blanching at the IV site. Fluid accumulation constricts local blood flow, leading to pale or blanched skin as an early visual cue of infiltration.

10. What is the earliest and most reliable sign of IV infiltration at the site?

    Swelling (edema) around the insertion site. Edema develops as leaked fluid accumulates in interstitial space, serving as an early indicator before other symptoms like pain or coolness appear.

11. Identify the key clinical difference between infiltration and extravasation.

    Extravasation involves a vesicant; infiltration involves a nonvesicant. The distinction lies in the fluid type: vesicants in extravasation cause tissue damage, while nonvesicants in infiltration typically result in mild edema.

12. Which option is the best prevention strategy during vesicant administration?

    Verify blood return and assess site frequently during infusion. Regular checks confirm patency and early detection of issues, preventing progression to significant infiltration or extravasation.

13. Which catheter selection principle reduces infiltration and extravasation risk?

    Use the smallest gauge that meets therapy needs. Smaller gauges minimize vein wall trauma and irritation, lowering risk of perforation and subsequent leakage.

14. Which assessment finding indicates decreased distal perfusion from infiltration?

    Weak distal pulse or delayed capillary refill. Significant infiltration can cause compartment syndrome-like effects, compressing vessels and impairing distal circulation.

15. Which patient population has increased risk for infiltration due to fragile veins?

    Older adults. Aging thins vein walls and reduces elasticity, increasing susceptibility to catheter dislodgement and fluid leakage.

16. Identify the best IV site choice to reduce extravasation risk for vesicant therapy.

    Large, stable vein (often forearm) and avoid hand/wrist when possible. Larger veins in stable areas like forearm provide better tolerance and less movement, reducing dislodgement risk during vesicant infusion.

17. Which patient report should be treated as a possible extravasation warning sign?

    Burning, stinging, or severe pain at the IV site. Vesicants irritate tissues upon leakage, eliciting intense localized pain as a critical early symptom requiring immediate intervention.

18. Which documentation element is essential after infiltration or extravasation occurs?

    Site assessment, drug/solution, actions taken, patient response, and notifications. Comprehensive records support continuity of care, legal protection, and evaluation of incident response effectiveness.

19. After stopping the infusion, what is the next action to limit tissue exposure?

    Disconnect tubing while leaving the catheter in place initially. Disconnecting tubing stops drug flow while preserving catheter access for potential aspiration or antidote administration.

20. Identify the correct action if a vesicant extravasation is suspected during infusion.

    Stop infusion, keep catheter for aspiration/antidote, then follow protocol. Immediate cessation halts further leakage, with catheter retention allowing drug removal or antidote delivery per guidelines.

21. What must the nurse do immediately after stabilizing the site in extravasation?

    Notify the provider and follow the facility extravasation protocol. Provider notification ensures prompt medical intervention, while protocol adherence guides antidote use and monitoring.

22. Which action is contraindicated when managing suspected extravasation?

    Flushing the IV line. Flushing forces more vesicant into tissues, exacerbating damage, so it's avoided to prevent worsening extravasation.

23. What skin temperature change is most consistent with IV infiltration?

    Coolness at and around the IV site. Leaked cool IV fluid lowers local tissue temperature, distinguishing infiltration from phlebitis, which often presents with warmth.

24. What is the correct action regarding limb positioning with infiltration or extravasation?

    Elevate the affected extremity. Elevation promotes venous return and reduces edema by facilitating fluid drainage from the affected area.

25. What IV pump or flow pattern change commonly occurs with infiltration?

    Slowed or stopped infusion, often with pump occlusion alarm. Tissue resistance from edema impedes flow, triggering pump alarms as pressure builds without proper venous return.

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