- A 46-year-old client with type 2 diabetes is receiving 0.9% NS at 125 mL/hr through a 20-gauge peripheral IV in the left forearm inserted 6 hours ago. The nurse notes swelling around the insertion site, cool skin, and the client reports tightness with minimal pain; the dressing is dry and intact and VS are BP 128/74, HR 84, RR 16, T 36.8°C (98.2°F). Which sign indicates infiltration at the IV site?
Answer: Coolness and swelling at the site with slowed or stopped infusion
This question tests recognition and management of IV therapy complications, specifically infiltration. The priority concern is preventing tissue damage from fluid leakage into surrounding tissues. The correct answer, coolness and swelling at the site with slowed or stopped infusion, is the best choice for client safety as it directly indicates infiltration, prompting immediate discontinuation of the IV to avoid further complications. Warmth, erythema, and a palpable cord suggest phlebitis; brisk blood return with painless flushing indicates a patent IV; and fever and chills may indicate infection or transfusion reaction, all of which are less optimal or incorrect for identifying infiltration. A key clinical judgment principle is to regularly assess IV sites for signs of complications like swelling and temperature changes. Another principle is to differentiate infiltration from other issues such as infection or phlebitis based on specific symptoms. A transferable strategy is to perform hourly IV site checks, including palpation and client feedback, to manage IV sites effectively and intervene early.
- A 76-year-old client with a history of fragile veins is receiving 0.9% NS at 75 mL/hr through a peripheral IV in the left forearm inserted 5 hours ago. The nurse notes the site is cool and pale with edema; the client reports discomfort and the pump alarms for occlusion. Which sign indicates infiltration at the IV site?
Answer: Cool, pale skin with edema and an occlusion alarm
This question tests recognition and management of IV therapy complications, specifically infiltration in an elderly client. The priority concern is avoiding compartment syndrome in clients with fragile veins. The correct answer, cool, pale skin with edema and an occlusion alarm, is the best choice for client safety as it signals infiltration needing intervention. Warmth with cordlike vein suggests phlebitis; fever and hypotension indicate sepsis; crackles suggest overload, all less optimal or incorrect. A key clinical judgment principle is to heed pump alarms as indicators of site issues. Another principle is to consider slower rates for elderly clients. A transferable strategy is to palpate sites for temperature and edema regularly to manage IV sites effectively.
- A 63-year-old client with heart failure is receiving IV furosemide intermittently through a 20-gauge peripheral IV in the right forearm inserted 4 hours ago. The nurse notes swelling and coolness at the site and the client reports discomfort during the last flush; there is no redness or warmth. Which sign indicates infiltration at the IV site?
Answer: Swelling with cool skin and discomfort during flushing
This question tests recognition and management of IV therapy complications, specifically infiltration in a client with heart failure. The priority concern is distinguishing infiltration from fluid overload to prevent misdiagnosis. The correct answer, swelling with cool skin and discomfort during flushing, is the best choice for client safety as it prompts IV assessment and potential removal. Warmth with purulent drainage suggests infection; rapid pulse and crackles indicate overload; blood return without swelling is normal, all less optimal or incorrect. A key clinical judgment principle is to correlate site-specific signs with systemic symptoms. Another principle is to avoid confusing local coolness with global fluid status. A transferable strategy is to flush IVs gently and observe for resistance or pain to manage IV sites effectively.
- A 7-year-old child with acute lymphoblastic leukemia is receiving vesicant chemotherapy via a tunneled central line; the infusion has been running for 20 minutes. The child suddenly reports burning pain at the catheter site, and the nurse notes localized erythema and swelling near the insertion area; VS are stable. What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion and keep the catheter in place to attempt aspiration per protocol
This question tests recognition and management of IV therapy complications, specifically extravasation during vesicant administration. The priority concern is preventing severe tissue damage and necrosis from vesicant leakage. The correct answer, stopping the infusion and keeping the catheter in place to attempt aspiration per protocol, is the best choice for client safety as it allows for potential removal of the extravasated drug and minimizes harm. Slowing the infusion delays intervention; removing the central line risks bleeding and loss of access; and delegating vital signs ignores the immediate need to address extravasation, all of which are less optimal or incorrect. A key clinical judgment principle is to act swiftly on signs of extravasation like pain and swelling during vesicant infusion. Another principle is to follow evidence-based protocols for antidote administration if indicated. A transferable strategy is to educate clients on reporting pain immediately and monitor high-risk infusions closely to manage IV sites effectively.
- A 38-year-old client in the ED has a new peripheral IV in the right antecubital area after multiple attempts. Thirty minutes after starting 0.9% NS at 200 mL/hr, the nurse notes localized swelling, coolness, and the client reports tightness at the site; no redness is present. Which sign indicates infiltration at the IV site?
Answer: Localized swelling and coolness with a feeling of tightness
This question tests recognition and management of IV therapy complications, specifically infiltration after multiple attempts. The priority concern is early detection to prevent extensive edema. The correct answer, localized swelling and coolness with a feeling of tightness, is the best choice for client safety as it indicates infiltration. Warm site with drainage suggests infection; chest pain and dyspnea indicate embolism; itching and hives suggest allergy, all less optimal or incorrect. A key clinical judgment principle is to reassess new IVs frequently after difficult insertions. Another principle is to educate on reporting tightness. A transferable strategy is to use ultrasound for vein location in challenging cases to manage IV sites effectively.
- A 54-year-old client with hypertension is receiving IV potassium chloride (KCl) 20 mEq in 100 mL NS over 1 hour through a 22-gauge peripheral IV in the left wrist started 4 hours ago. After 10 minutes, the client reports burning pain rated 8/10 and the nurse notes blanching, swelling, and cool skin around the site with minimal blood return. What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion and follow facility protocol for suspected extravasation
This question tests recognition and management of IV therapy complications with high-risk medications like potassium chloride. The priority concern is preventing severe tissue damage from extravasation of irritating medications that can cause necrosis. Stopping the infusion and following facility protocol for suspected extravasation (Option A) is the correct priority action because potassium chloride is highly irritating to tissues and can cause severe damage if extravasated. Option B (decreasing rate and warm compress) would continue tissue exposure and potentially worsen injury, Option C (documenting and monitoring) delays critical intervention, and Option D (delegating IV restart) is inappropriate delegation and doesn't address the immediate threat. The clinical judgment principle is that medications with pH extremes or high osmolarity require immediate intervention if extravasation is suspected. A transferable strategy for preventing extravasation of high-risk medications is to use larger veins, verify patency before administration, dilute appropriately, and monitor closely throughout infusion.
- A 78-year-old client with thin, fragile skin is receiving IV antibiotics through a 24-gauge peripheral IV in the left wrist inserted 8 hours ago. The nurse observes the area is cool and pale with mild swelling, and the client reports a tight sensation; the IV is sluggish to flush. Which sign indicates infiltration at the IV site?
Answer: Coolness, pallor, and swelling with resistance to flushing
This question tests recognition and management of IV therapy complications, specifically infiltration in a client with fragile skin. The priority concern is preventing skin breakdown and further injury from fluid infiltration. The correct answer, coolness, pallor, and swelling with resistance to flushing, is the best choice for client safety as it indicates the need for immediate IV discontinuation. Warmth with red streaking suggests phlebitis; wheezing and hives indicate allergy; localized itching may be tape reaction, all less optimal or incorrect. A key clinical judgment principle is to select appropriate sites and gauges for fragile veins. Another principle is to assess flush resistance as a patency indicator. A transferable strategy is to use transparent dressings for easy visualization and frequent checks to manage IV sites effectively.
- A 9-year-old child receiving vesicant chemotherapy via a central venous catheter has new erythema and reports burning pain at the insertion site during the infusion. The nurse also notes slight swelling; VS remain stable. Which symptom requires IMMEDIATE intervention by the nurse?
Answer: Burning pain and erythema at the catheter site during vesicant infusion
This question tests recognition and management of IV therapy complications, specifically immediate intervention for suspected extravasation in a child. The priority concern is preventing necrosis from vesicant leakage. The correct answer, burning pain and erythema at the catheter site during vesicant infusion, is the best choice for client safety as it requires stopping the infusion immediately. Mild anxiety, heart rate increase, or dried drainage are less critical and not signs of extravasation. A key clinical judgment principle is to prioritize pain and erythema as red flags in vesicant therapy. Another principle is to assess pediatric clients frequently due to communication challenges. A transferable strategy is to teach families to report burning sensations promptly to manage IV sites effectively.
- A 57-year-old client with COPD is receiving continuous IV fluids through a peripheral IV in the left forearm placed 9 hours ago. The nurse assesses the site and finds marked swelling, taut skin, and blistering with severe burning pain; there is minimal blood return. What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion, leave the catheter in place, and initiate extravasation management per protocol
This question tests recognition and management of IV therapy complications, specifically extravasation in a client with COPD. The priority concern is preventing respiratory compromise from pain or swelling. The correct answer, stopping the infusion, leaving the catheter in place, and initiating extravasation management per protocol, is the best choice for client safety as it addresses the issue directly. Elevating without stopping continues risk; flushing may worsen; delegating is inappropriate, all less optimal or incorrect. A key clinical judgment principle is to recognize taut skin as advanced extravasation. Another principle is to monitor for systemic effects in comorbid clients. A transferable strategy is to check blood return before continuous infusions to manage IV sites effectively.
- A 46-year-old client with type 2 diabetes is receiving 0.9% NS at 125 mL/hr through a 20-gauge peripheral IV in the left forearm inserted 10 hours ago on a medical-surgical unit. The nurse notes localized swelling around the insertion site, skin cool to touch, and the client reports tightness rated 3/10; there is minimal redness and the IV is infusing sluggishly. Which sign indicates infiltration at the IV site?
Answer: Cool, pale skin with swelling and a slowed infusion rate
This question tests recognition and management of IV therapy complications, specifically identifying signs of infiltration. The priority concern is recognizing infiltration early to prevent tissue damage from fluid accumulation in surrounding tissues. Cool, pale skin with swelling and a slowed infusion rate (Option B) correctly identifies the classic triad of infiltration: coolness from non-warmed fluid in tissues, pallor from compressed capillaries, and swelling from fluid accumulation outside the vein. Option A describes phlebitis (vein inflammation), Option C indicates a patent IV with no complications, and Option D suggests systemic infection rather than a local complication. The clinical judgment principle is that infiltration presents with local signs of fluid in tissues (cool, swollen, slow flow) rather than inflammatory signs. A transferable strategy is to assess IV sites systematically using the mnemonic REEDA: Redness, Edema, Ecchymosis, Drainage, and Approximation, while also checking temperature and flow rate.
- A 55-year-old post-operative client (POD 1 after abdominal surgery) is receiving D5 0.45% NS with 20 mEq KCl at 100 mL/hr through a 20-gauge peripheral IV in the left antecubital fossa inserted 10 hours ago. The nurse finds blistering and intense burning pain at the site with taut swelling and minimal blood return; VS are BP 136/80, HR 92, RR 18, T 37.1°C (98.8°F). What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion, leave the IV catheter in place, and follow facility extravasation protocol
This question tests recognition and management of IV therapy complications, specifically extravasation in a post-operative client. The priority concern is preventing tissue necrosis from irritant fluid leakage. The correct answer, stopping the infusion, leaving the IV catheter in place, and following facility extravasation protocol, is the best choice for client safety as it facilitates aspiration and antidote application if needed. Applying a warm compress may worsen damage; flushing could push more fluid into tissues; and notifying the provider without stopping delays action, all less optimal or incorrect. A key clinical judgment principle is to prioritize stopping the source of extravasation immediately. Another principle is to document the incident and monitor for long-term effects like ulceration. A transferable strategy is to inspect IV sites before and during infusions, especially with additives like potassium, to manage IV sites effectively.
- A 29-year-old client in the ED with dehydration has had multiple IV attempts; a new 18-gauge peripheral IV was placed in the right forearm 30 minutes ago and is infusing lactated Ringer's at 150 mL/hr. The nurse notes increasing swelling and coolness at the site and the client reports a feeling of pressure; the infusion pump alarms for occlusion. Which symptom requires IMMEDIATE intervention by the nurse?
Answer: Cool, swollen tissue around the IV with an occlusion alarm
This question tests recognition and management of IV therapy complications, specifically immediate intervention for infiltration. The priority concern is preventing further fluid extravasation and potential tissue damage. The correct answer, cool, swollen tissue around the IV with an occlusion alarm, is the best choice for client safety as it requires stopping the infusion to avoid complications. Dried blood under the dressing, mild bruising, or a bathroom request do not indicate active infiltration and are less urgent. A key clinical judgment principle is to respond to pump alarms and site changes promptly. Another principle is to evaluate multiple symptoms like swelling and client reports together. A transferable strategy is to teach clients to report pressure sensations and check sites after multiple attempts to manage IV sites effectively.
- A 50-year-old post-operative client is receiving continuous IV fluids through a peripheral IV in the right forearm. The nurse finds blistering, taut edema, and intense pain at the site; the client reports burning and the pump alarms for occlusion. What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion and follow extravasation protocol while leaving the catheter in place
This question tests recognition and management of IV therapy complications, specifically extravasation post-operatively. The priority concern is alleviating severe pain and preventing necrosis. The correct answer, stopping the infusion and following extravasation protocol while leaving the catheter in place, is the best choice for client safety as it allows intervention. Restarting first delays; continuing with warmth worsens; notifying without stopping is inadequate, all less optimal or incorrect. A key clinical judgment principle is to respond to occlusion alarms promptly. Another principle is to evaluate for blistering as a severity marker. A transferable strategy is to integrate pump data with clinical findings to manage IV sites effectively.
- A 52-year-old client is receiving IV vancomycin through a peripheral IV in the right forearm inserted 1 day ago. The nurse notes swelling and coolness at the site with discomfort during flushing; there is no warmth or streaking. Which symptom requires IMMEDIATE intervention by the nurse?
Answer: New swelling and coolness at the IV site with pain on flushing
This question tests recognition and management of IV therapy complications, specifically immediate intervention for infiltration during antibiotic infusion. The priority concern is preventing further discomfort and tissue damage. The correct answer, new swelling and coolness at the IV site with pain on flushing, is the best choice for client safety as it requires IV discontinuation. Infusion delay, metallic taste, or tape redness are less urgent. A key clinical judgment principle is to assess for infiltration with irritant drugs like vancomycin. Another principle is to avoid confusing side effects with site complications. A transferable strategy is to flush and observe for pain before and after doses to manage IV sites effectively.
- A 60-year-old post-operative client is receiving IV fluids through a peripheral IV in the left forearm. The nurse finds intense pain, swelling, and blistering at the site 2 hours after starting an IV potassium-containing maintenance fluid; the client states the pain is severe and worsening. What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion and leave the catheter in place to manage per extravasation protocol
This question tests recognition and management of IV therapy complications, specifically extravasation of potassium-containing fluids. The priority concern is mitigating severe tissue irritation from hypertonic solution leakage. The correct answer, stopping the infusion and leaving the catheter in place to manage per extravasation protocol, is the best choice for client safety as it prevents further exposure. Removing and applying pressure loses aspiration opportunity; continuing with warmth may increase damage; delegating massage is unsafe, all less optimal or incorrect. A key clinical judgment principle is to recognize blistering as a severe sign. Another principle is to follow specific protocols for irritants. A transferable strategy is to monitor additive infusions closely and intervene at first sign of pain to manage IV sites effectively.
- A 29-year-old client is receiving IV cefazolin through a 20-gauge peripheral IV in the left forearm started 2 hours ago. The nurse observes swelling at the site, cool skin, and the client reports tightness rated 2/10; there is no redness or drainage, and vital signs are stable. What is the nurse's PRIORITY action if infiltration is suspected?
Answer: Stop the infusion, remove the IV catheter, elevate the extremity, and restart IV access in a new site
When a peripheral IV site shows swelling, coolness, and tightness, infiltration has already occurred. The priority is to stop the infusion, remove the catheter, elevate the extremity so the leaked fluid can be reabsorbed, and then restart IV access in a new site to continue the antibiotic. Delaying the response allows more of the drug to accumulate in the surrounding tissue, so continuing the infusion and reassessing at the end of the antibiotic dose is unsafe even when the tightness is mild. Massaging the area — especially when delegated to a UAP — can force infiltrated fluid deeper into the tissues, is not an evidence-based treatment, and involves a task that cannot be delegated. Waiting for a provider order before stopping the infusion also delays necessary action: discontinuing an IV for suspected infiltration is a nursing-driven intervention that does not require an order, even when vital signs are stable. The tested contrast is acting promptly and independently on signs of infiltration rather than deferring, delegating, or treating the problem as mild.
- An 80-year-old client with peripheral vascular disease is receiving IV fluids through a 22-gauge peripheral IV in the right hand inserted 3 hours ago. The nurse notes the hand is cool and pale with swelling around the IV site, and the client reports discomfort; the infusion is sluggish. Which symptom requires IMMEDIATE intervention by the nurse?
Answer: Cool, pale, swollen IV site with sluggish infusion
This question tests recognition and management of IV therapy complications, specifically immediate intervention for infiltration in a vulnerable client. The priority concern is protecting circulation in peripheral vascular disease. The correct answer, cool, pale, swollen IV site with sluggish infusion, is the best choice for client safety as it demands prompt action. Requests for water, elevated BP, or small ecchymosis are less urgent. A key clinical judgment principle is to prioritize site assessments in high-risk clients. Another principle is to correlate sluggish flow with physical findings. A transferable strategy is to choose distal sites carefully and monitor perfusion to manage IV sites effectively.
- A 33-year-old client in the ED is receiving IV fluids through a newly placed peripheral IV after multiple attempts. The nurse notes swelling and coolness at the most recent insertion site and the client reports tightness; VS are stable. Which symptom requires IMMEDIATE intervention by the nurse?
Answer: Swelling and coolness at the current IV site with client-reported tightness
This question tests recognition and management of IV therapy complications, specifically immediate intervention for infiltration after multiple attempts. The priority concern is early detection in unstable access. The correct answer, swelling and coolness at the current IV site with client-reported tightness, is the best choice for client safety as it requires intervention. Bruising at old site, hunger, or damp tubing are less critical. A key clinical judgment principle is to prioritize new site assessments. Another principle is to validate client reports of tightness. A transferable strategy is to stabilize difficult IVs with secure dressings and monitor closely to manage IV sites effectively.
- A 6-year-old child receiving vesicant chemotherapy via an implanted port reports stinging pain at the port site 10 minutes into the infusion. The nurse notes localized swelling and blanching around the port needle insertion; VS are BP 98/60, HR 110, RR 22, T 37.0°C (98.6°F). What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion and attempt to aspirate any remaining drug per protocol
This question tests recognition and management of IV therapy complications, specifically extravasation in a pediatric client with an implanted port. The priority concern is minimizing tissue damage from vesicant exposure in a child. The correct answer, stopping the infusion and attempting to aspirate any remaining drug per protocol, is the best choice for client safety as it reduces the amount of extravasated vesicant. Removing the port needle loses access; documenting without action delays care; delegating restarts ignores priority, all less optimal or incorrect. A key clinical judgment principle is to recognize pediatric pain reports as critical indicators. Another principle is to maintain line access for potential interventions. A transferable strategy is to monitor port sites closely during infusions and involve parents in reporting changes to manage IV sites effectively.
- A 5-year-old child is receiving vesicant chemotherapy via a central line. The nurse notes the child is crying and reports burning pain at the site, and the area is erythematous with mild swelling. What is the nurse's PRIORITY action if extravasation is suspected?
Answer: Stop the infusion immediately and follow the facility extravasation protocol
This question tests recognition and management of IV therapy complications, specifically extravasation in a pediatric vesicant infusion. The priority concern is rapid response to prevent long-term tissue damage in children. The correct answer, stopping the infusion immediately and following the facility extravasation protocol, is the best choice for client safety as it halts further leakage. Slowing delays care; removing and heating is incorrect; calling without stopping is passive, all less optimal or incorrect. A key clinical judgment principle is to interpret crying and pain as urgent in pediatrics. Another principle is to prepare extravasation kits in advance. A transferable strategy is to pause infusions at first complaint and assess thoroughly to manage IV sites effectively.
