NCLEX^® QUESTION OF THE WEEK

Question of the Week – August 17, 2022

August 17, 2022

The nurse checks the client’s peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and that the fluid is not infusing. Which condition should the nurse report and document?

Show Answer Answer

Correct! The answer is number 3

Rationale:

Answer: 3

Rationale: The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and plan for insertion of a new IV. All the remaining options are likely to be accompanied by warmth at the site. Eliminate options 1, 2, and 4 that suggest the site appearance as being reddened.

Additional Info

Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Complex Care: Intravenous Therapy
Health Problem: Adult Health: Integumentary: Inflammations/Infections

Practice Question Sourced From: Saunders Q & A Review for the NCLEX-PN® Examination, 5th Edition