Drag each assessment cluster to the most likely complication of peripheral IV therapy.
Matrix Multiple Choice
Choose your responses, then check the answer.
Explanation
Infiltration produces swelling, coolness, pallor or tightness, leaking, and slowed flow at the site. Phlebitis produces warmth, erythema, tenderness, and sometimes a palpable venous cord. Fluid overload is systemic and may produce dyspnea, crackles, falling oxygen saturation, jugular venous distention, or rapid weight gain.
Quick answer Cool swollen site = infiltration; warm tender vein = phlebitis; respiratory and volume findings = fluid overload.
Why this is correct Local site findings distinguish infiltration from phlebitis, while pulmonary or circulatory findings signal systemic fluid excess. A vesicant leak is extravasation and requires the agent-specific protocol; this item limits the local leak examples to nonvesicant fluid.
NCLEX decision rule Stop a concerning infusion and assess before attempting to flush. Protect the client first, then follow facility policy for catheter removal, aspiration, compresses, elevation, escalation, and documentation.
References
1NCBI Open RN: local complications of peripheral IV therapy
2NCBI Open RN: peripheral IV access
Peripheral IV reassessmentSeveral adults are receiving nonvesicant IV fluids. The nurse compares the insertion site with systemic findings before stopping the infusion and following the complication-specific facility protocol.
Infiltration — Unintended leakage of a nonvesicant IV solution into surrounding tissue.
Phlebitis — Inflammation of a vein associated with pain, warmth, erythema, and sometimes a palpable cord.
Fluid Overload — Excess intravascular volume that may produce dyspnea, crackles, reduced oxygenation, jugular venous distention, or rapid weight gain.