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A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

Dryness

Edema

Erythema

A distended vein

Answer and Explanation

The Correct Answer is B

A. Dryness – Infiltration leads to swelling and fluid accumulation, not dryness.

B. Edema – Infiltration occurs when IV fluids leak into surrounding tissue, causing swelling (edema).

C. Erythema – While redness (erythema) can indicate phlebitis, it is not a primary sign of infiltration.

D. A distended vein – A distended vein is more likely seen with fluid overload or thrombosis, not infiltration.

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Correct Answer is B

Explanation

A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.

B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.

C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.

D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.

A. Attach a probe carefully to the client's finger to prevent discomfort. B. Apply a sensor pad to the client's forehead. C. Secure a probe to one of the client's toes. D. Obtain a pulse oximetry reading when peripheral edema has decreased.

Correct Answer is B

Explanation

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

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A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

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