A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
(Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).
Remove the IV catheter.
Apply warm or cold compresses.
Stop the infusion.
Apply a sterile dressing.
Elevate the extremity.
The Correct Answer is C,A,D,E,B
Here’s the correct order of actions a nurse should take when infiltration is identified at an IV site: C. Stop the infusion A. Remove the IV catheter D. Apply a sterile dressing E. Elevate the extremity B. Apply warm or cold compresses ? Rationale: Stopping the infusion prevents further infiltration. Removing the catheter eliminates the source of fluid leakage. Applying a sterile dressing protects the site from infection. Elevation helps reduce swelling. Compresses (warm for older infiltrations, cold for recent ones) promote absorption and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Choice A rationale:
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Choice B rationale:
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Choice C rationale:
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Choice D rationale:
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