NUR172 Lab Exam #1

When preforming a venipuncture, remember the following:

-Do not use the inner wrist because of the high risk for damage to underlying structures. -Avoid areas that are edematous, paralyzed, burned, scarred, have a tattoo, or are on the same side as a mastectomy, arteriovenous shunt, or graft. -Avoid an extremity affected by a cerebrovascular accident, areas of infection, or areas with abnormal skin conditions. -Do not draw blood from the same extremity being used for administration of intravenous medications, fluids, or blood transfusions. Some facilities will allow use of such sites as a "last resort," after the infusion has been held for a period of time. If necessary, choose a site distal to the intravenous access site.

When caring for a client who requires intravenous (IV) therapy, which actions are within the nurse's scope of practice and can be performed independently?

-deciding to relocate an IV site that has infiltrated -deciding on the peripheral IV site location -determining what gauge IV catheter to use

The nurse is capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions.

1)Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. 2)Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. 3)Aspirate the catheter for positive blood return by gently pulling back on the syringe. 4)Flush the tubing slowly, over one minute, with a sterile saline filled syringe. 5)Reclamp the extension tubing and loop it near the entry site, securing it with tape. Rationale:When capping an IV line, the nurse begins by disinfecting the needleless connector or end cap on the extension tubing, vigorously scrubbing it with an antimicrobial swab, and then allowing it to dry. Next, the nurse should insert the saline flush syringe into the end cap and aspirate for a blood return to confirm patency before administering fluids or medications. After getting a blood return, the nurse should slowly flush the line with sterile saline over one minute, and then reclamp the extension tubing to prevent air from entering. Lastly, the nurse should loop the line near the entry site to prevent the weight of the tubing from dislodging the catheter and secure it with tape.

order of blood draws **HINT: Boys Like Rad Gorls Greeting Love Punked Gremlins" Or think of a stop light.... sky, light, sidewalk, then off to the side

1. Blood Cultures 2. Light Blue Top 3. Red Top 4. Gold Top 5. Green Top 6. Lavender Top 7. Pink Top 8. Grey Top

what is the correct sequence of removing PPE?

1. GLOVES 2. GOGGLES OR FACE SHIELD 3. GOWN 4. MASK OR RESPIRATOR 5. WASH HANDS IMMEDIATELY AFTER REMOVING ALL PPE

what is the correct sequence of donning PPE?

1. GOWN 2. MASK OR RESPIRATOR 3. GOGGLES OR FACE SHIELD 4. GLOVES

WHAT IS AN ALTERNATE EX OF REMOVING PPE?

1. GOWN AND GLOVES 2. GOGGLES OR FACE SHIELD 3. MASK OR RESPIRATOR 4. WASH HANDS IMMEDIATELY AFTER REMOVING ALL PPE

Arrange in the correct order to doff PPE: Hand Hygiene Mask Gloves Gown Goggles

1. Gloves 2. Goggles 3. Gown 4. Mask 5. Hand Hygiene

Arrange the following in the proper order to don PPE: Hand Hygiene Mask Gloves Gown Goggles

1. hand hygiene 2. Gown 3. Mask 4. Goggles 5. Gloves

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?

10- to 15-degree angle

What range of suction pressure should be used while suctioning a tracheostomy? Why?

100 - 150mm Hg for adults (no more than 80 for neonates) Any more pressure can cause hypoxemia, atelectasis,

What angle should the needle bevel up when performing venipuncture?

15 to 30 degrees

How long should pressure be applied to the puncture site after the needle has been withdrawn?

2-3 minutes, or until the bleeding stops. *** If a patient has a clotting disorder or is receiving anticoagulant therapy, maintain firm pressure on the venipuncture site for at least 5 minutes after withdrawing the needle to prevent hematoma formation.

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy? A. An older adult client receiving an IV infusion for pneumonia. B. A teenager receiving an IV infusion for dehydration. C. An adult injured in a car accident receiving medication via an IV infusion. D. An infant receiving an IV infusion for bronchitis.

A. An older adult client receiving an IV infusion for pneumonia. Rationale:Although any client receiving IV therapy could develop fluid overload, older adult clients are more at risk for fluid overload due to the possible decrease in cardiac and/or renal functions.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. A. Gauge and length of the IV catheter B. Location of the IV catheter access C. Manufacturer of the IV catheter D. Client's reaction to the procedure E. Type of IV solution F. Rate of the IV solution

A. Gauge and length of the IV catheter B. Location of the IV catheter access D. Client's reaction to the procedure E. Type of IV solution F. Rate of the IV solution

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding? A. Shortness of breath. B. Pounding headache. C. Change in the level of consciousness. D. Deceased blood pressure.

A. Shortness of breath. Rationale:Fluid overload is caused when too large a volume of fluid infuses into the circulatory system. This complication manifests as engorged neck veins, shortness of breath and abnormal breath sounds (suggesting respiratory failure), increased blood pressure, and difficulty breathing. A pounding headache is a sign of speed shock and the change in level of consciousness is related to the existence of an air embolus.

What are the 2 blood draws that must be sent to the lab on ice & what is the proper order of collection?

Ammonia and Lactic Acid Green Top then Gray Top

When collecting a blood sample via venipuncture, when should the tourniquet be removed?

As soon as blood flows adequately into the collection tube

Where should you remove all of your PPE?

At the doorway

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs? A. Upon discharge. B. Beginning of the work shift. C. End of the work shift. D. Upon admission.

B. Beginning of the work shift. Rationale:The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial client assessment and at the beginning of a work shift. In addition, IV sites would be checked at specific intervals and each time an IV medication is given, per the institution's policies.

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy? A. Infection B. Phlebitis C. Sepsis D. Thrombus

B. Phlebitis

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate? A. Disconnect the tubing from the client to purge the air from the tubing. B. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. C. Make sure the flow clamp is open and that the drip chamber is approximately half full. D. Change the IV solution administration set immediately.

B. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger.

The nurse, who is monitoring the IV site of a client receiving peripheral venous fluid therapy, checks for bleeding at the site. The nurse understands that bleeding at an IV site is most likely to occur at which time? A. When the IV is infusing. B. When the IV is discontinued. C. When the IV solution is changed. D. When the IV is initiated.

B. When the IV is discontinued.

Why are antecubital veins not a good choice for IV infusions?

BC flexion of the patient's arm can displace the IV catheter over time by avoiding the antecubital vein for peripheral venous catheters, a PICC line may be inserted at a later time if needed

Asking the patient to pump their fist when finding a distended vein is contraindicated. Why?

Because this may increase plasma potassium levels. You may ask then to make a fist, try tapping the skin very lightly several times, lower the patients arm to allow for blood to pool in the lower extremities, or apply a warm compress for 10 minutes before reapplying the tourniquet

Why is there a specific order to drawing blood?

Because you don't want to cross-contaminate the collection needle. e.g. with any coags that may be present in the the tube EG why the light blue top is first

A pink top tube containing EDTA is primarily used for?

Blood Bank Tests

What tubes contain EDTA?

Blood Culture Lavender Top Pink Top

The nurse is initiating a continuous intravenous (IV) infusion. Place in order the steps the nurse will take. A. Squeeze the drop chamber and allow it to fill halfway. B. Open the roller clamp on the IV tubing. C. Close the roller clamp on the IV tubing. D. Replace the end cap on the end of the IV tubing. E. Spike the new bag of IV fluid and hang it on the IV pole. F. Carefully observe IV fluid move through the tubing until no air remains.

C. Close the roller clamp on the IV tubing. E. Spike the new bag of IV fluid and hang it on the IV pole. A. Squeeze the drop chamber and allow it to fill halfway. B. Open the roller clamp on the IV tubing. F. Carefully observe IV fluid move through the tubing until no air remains. D. Replace the end cap on the end of the IV tubing.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? A. Apply a new dressing and observe for signs of infection over the next several hours. B. Decontaminate the visible portion of the catheter, and then gently reinsert. C. Remove the IV catheter and reinsert another in a different location. D. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

C. Remove the IV catheter and reinsert another in a different location.

What are the appropriate steps to take if the nurse observes IV not flowing as easily as it previously was?

Check all clamps on the tubing and check the tubing for any kinking. Check that the patient is not lying on the tubing. If the IV is over a joint, reposition the extremity and see if this helps the flow. Attempt to flush the IV with 2 to 3 mL of normal saline. If the IV is painful or you meet resistance when attempting to flush, discontinue the IV and restart in another place.

A nurse is collecting a venous blood specimen from an adult for culture and sensitivity. Which actions should the nurse perform?

Clean the client's skin at the puncture site with an antimicrobial swab., Collect blood-culture specimens before other specimens., Collect the specimens from two different sites., Collect two bottles of specimen, totalling 30 mL. Rationale:If tests are prescribed in addition to the blood cultures, the nurse should collect the blood-culture specimens before other specimens, to lessen the likelihood that the culture samples will be contaminated due to other tests. In this procedure, a venous blood sample is collected by venipuncture into two bottles (one set), one containing an anaerobic medium and the other an aerobic medium. Currently, best practice is to draw blood one time, obtaining at least 30 mL of blood (for adults) from two different venipuncture sites. Cleaning the client's skin reduces the risk for transmission of microorganisms. With the bevel of the needle up, the nurse should insert the needle into the vein at a 15-degree angle to the skin, not a 45-degree angle.

Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use?

Client who is only receiving fluids at a keep-vein-open rate Client who needs infusions of an antibiotic only every 12 hours Client who no longer requires intravenous infusions. Rationale:The client who needs infusion of an antibiotic only every 12 hours is a good candidate for capping of an existing intravenous line for intermittent use, because the client now requires only twice daily infusions, not continuous infusions. The client who no longer requires IV infusions is a good candidate, because capping the line maintains IV access in case of an emergency; it is a typical hospital policy to do so. The client who is solely receiving fluids at a keep-vein-open rate is a good candidate for capping of an existing intravenous line, because continuous fluids are not needed to keep the vein open and the line patent. The client receiving a continuous infusion of normal saline at 60 mL/hour is not a good candidate, because the client still need continuous infusions. The client who is tolerating clear liquids is not a good candidate. The most common reasons for a client to be on a clear liquid diet is because the client recently had surgery, is experiencing nausea/vomiting, or has a bowel obstruction; in any of these cases, the client would need continuous infusions.

When hanging a new bag of IV fluid for a client, which action does the nurse perform first?

Close the roller clamp on the tubing

Blood Cultures

Culture & Sensitivity (C&S) draw 1st

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client? A. A client who has fluid imbalances. B. A client who is unconscious. C. A client who is dehydrated. D. A client who is receiving IV medications.

D. A client who is receiving IV medications.

A client has a peripheral access IV infusion running via an electronic infusion device. While monitoring the infusion, the nurse notices that the electronic infusion device is not running. What should the nurse do? A. Check the IV connector to ensure the clamp is closed. B. Attempt to flush the IV with 5 to 10 mL saline in a syringe. C. Lower the height of the pole. D. Check the electronic device for proper functioning.

D. Check the electronic device for proper functioning.

The nurse is monitoring an IV site for a client who reports that the needle feels "funny." What should the nurse do first? A. Reassure the client that this is a normal feeling associated with an IV infusion. B. Remove the catheter and apply a gauze dressing. C. Discontinue the IV infusion and notify the health care provider. D. Check the integrity of the IV system, IV solution and tubing, and flow rate.

D. Check the integrity of the IV system, IV solution and tubing, and flow rate.

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate? A. Discontinue the IV and start it at another site. If phlebitis worsens, notify the health care provider. B. Keep the IV in place, notify the health care provider, and start treatment for phlebitis. C. Keep the IV in place until the solution has been infused, and then discontinue it and notify the health care provider. D. Notify the health care provider, discontinue the IV, and start it at another site.

D. Notify the health care provider, discontinue the IV, and start it at another site.

How often should an IV site dressing be changed?

Dressing changes for short peripheral catheters are performed every 5 to 7 days, or if the dressing becomes damp, loosened, and/or visibly soiled. However, dressing changes might be required more often, based on nursing assessment and judgment. Immediately change any dressing that is damp, loosened, or soiled. In the event of drainage, site tenderness, or other signs of infection, change the dressing

What does EDTA stand for? What is EDTA's Fx?

Ethylenediaminetetraacetic acid It functions by binding calcium in the blood and keeping the blood from clotting.

Hoe often should an IV site be monitored?

Every hour, although it may change depending on facility policy

T or F? It is ok to set a sterile package down on a wet surface?

FALSE

T or F? When putting on sterile gloves you should start with your non-dominant hand.

FALSE; you should start with your dominant hand

When performing endotracheal suctioning, what position should the patient be in?

If conscious, the patient should be in semi fowler's position. If unconscious, the patient should be in lateral position facing you

For which age group is the foot an appropriate site for IV insertion?

Infant

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse's suspicions?

PALLOR, COOLNESS, SWELLING, LEAKAGE

When checking the specimen label with the patient's ID bracelet, what info should be included on the specimen label?

PT name PT ID # Time of specimen collection route of collection ID of the person obtaining the sample any other info required by facility

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

Pink Top

Stopper (EDTA) Type and crossmatch, Rh, antibody screen Draw 7th

Lavender Top

Stopper (EDTA) Whole Blood, Hematology CBC, H&H, Sedrate/ESR (Erythrocyte Sedimentation Rate) , Retic Count Draw 6th

Green/Mint Top

Stopper (Heparin) STAT Plasma, CMP, ChemistryAmmonia, Electrolytes, ABG's, HgbA1C, Lipase, Cardiac Enzymes Draw 5th

Light Blue Top

Stopper (Na Citrate) PT/PTT, D-Dimer, Fibrinogen Draw 2nd

Red Top

Stopper (No addicitve) Type and crossmatch, Rh, antibody screen Draw 3rd

Gold Top

Stopper (SST) Serum Separator Tubes Bilirubin, Electrolytes, BMP (lytes, Na, K), CMP (liver panel & BMP) Draw 4th

Gray Top

Stopper (Thrombin/ Na Fluoride) STAT Lactic Acid Fasting Blood Sugar (FBS) "not STAT" Draw 8th

T or F? When collecting a blood sample via venipuncture, the same contraindications apply as initiating an IV. Meaning: if a patient has had a mastectomy then the sample will want to be taken from the other side

TRUE

What is the difference between the Blood Culture and Red Tubes?

The Blood Culture tube contians EDTA. The Red tube has no additive.

After you feel the tube push into place on the puncture device, bloods flows into the tube automatically. Why is this?

The collection tube is a vacuum; negative pressure within the tube pulls blood into the tube

A nurse needs to obtain a venous blood sample from a term neonate. On the basis of recent research, which is the method of choice for collecting this client's sample?

Venipuncture with butterfly needle Rationale:Recent research indicates that venipuncture, when performed by a skilled phlebotomist, appears to be the method of choice rather than a heel lance, which is more painful. The nurse should use butterfly needles, as appropriate, for obtaining blood from infants and small children. A finger lancet is used to obtain a capillary blood sample for glucose testing in adults.

A nurse is assessing a client's intravenous (IV) site while changing the dressing. Which signs would indicate fluid infiltration into the tissue around the IV catheter? Select all that apply. a. Swelling b. Warmth c. Redness d. Coolness e. Pallor

a. Swelling d. Coolness e. Pallor

The nurse is caring for a client who has been diaphoretic and observes that the dressing on the peripheral venous access site has become loose and needs changing. Which type of dressing would be best for this client? a. a sterile gauze dressing b. 2 × 2 gauze with foam tape d. clear non-permeable occlusive dressing d. a transparent semi-permeable membrane dressing

a. a sterile gauze dressing Rationale:A sterile gauze dressing is the best choice for this client, as it will absorb the extra moisture caused by the diaphoresis. Once the diaphoresis is resolved, the dressing should be changed to a transparent semi-permeable membrane dressing (TSM). TSM dressings allow easy inspection of the IV site and, because they are semi-permeable, permit evaporation of moisture that accumulates under the dressing normally. Non-permeable dressings are not recommended, because they do not allow evaporation of moisture. A dressing with foam tape is not recommended, because it does not allow visualization of the site.

Which action by the nurse is most important to ensure the client's safety when changing a peripheral venous access device dressing? a. placing the bed in the lowest position before leaving the room b. inspecting the access site for redness and inflammation c. gathering all equipment before entering the client's room d. using a semi-permeable dressing to cover the site

a. placing the bed in the lowest position before leaving the room Rationale:While all actions are correct, the one that is most important to ensure the client's safety is to place the bed back into the lowest position before leaving the room. This action helps to prevent falls or injuries when the client is getting out of the bed. Using a semi-permeable dressing allows moisture to evaporate. Gathering all equipment before entering the client's room helps the nurse be prepared and organized. Inspecting the site allows the nurse to recognize complications early and address them as needed.

Sepsis

aka infection, is caused by invasion of microorganisms. -is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes.

Phlebitis

an inflammation of a vein caused by mechanical trauma from a needle or catheter. -characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site.

The nurse is assessing a client's peripheral venous access site and notes redness and inflammation at the site. What is the best action by the nurse at this time? a. Change the site dressing using aseptic technique. b. Discontinue current IV and relocate to new site. c. Document the findings and continue to closely monitor the site. d. Notify the health care provider of the findings and request prescription for an antibiotic.

b. Discontinue current IV and relocate to new site.

Which situation would warrant the need for the nurse to change a client's venous access dressing? a. The IV infusion rate has slowed. b. The skin around the site is wet. c. The tubing is looped near the site of entry. d. The client is complaining of pain at the site.

b. The skin around the site is wet.

The nurse is preparing to insert an intravenous catheter into an adult client. Place the following steps in the correct order. Use all options. a. Release the tourniquet. b. Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. c. Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. d. Insert the needle gently. e. Cleanse the site with chlorhexidine. f. Stabilize the catheter or needle.

c. Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. e. Cleanse the site with chlorhexidine. b. Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. d. Insert the needle gently. a. Release the tourniquet. f. Stabilize the catheter or needle.

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? a. Sealed IV dressing b. Transparent semipermeable membrane dressing c. Gauze dressing d. Occlusive dressing

c. Gauze dressing

The nurse changes a client's peripheral venous access dressing. Which nursing action is correct? a. Apply an antibacterial ointment to all the skin area that will be covered with the dressing. b. Label the new dressing with the client's name, date of birth, and initials. c. Loop the intravenous tubing near the entry site and secure it under the access dressing. d. Press the chlorhexidine applicator against the skin using a back-and-forth motion.

d. Press the chlorhexidine applicator against the skin using a back-and-forth motion. Rationale:The nurse is correct in pressing the chlorhexidine applicator against the skin and applying it using a back-and-forth motion. The label should include the date and time the dressing was changed and the nurse's initials, not the client's name or date of birth. The nurse is correct in applying skin protectant to all the skin that would be covered by the dressing, but an antibacterial ointment is not used. Looping the IV tubing near the entry site and taping it in place is correct, but securing it under the access dressing can lead to increased infection or accidental removal of the IV catheter.

What information should be documented after collecting a blood sample via venipuncture?

date, time, and site of the venipuncture; the name of the test(s); the time the sample was sent to the laboratory; the amount of blood collected, if required; and any significant assessments or patient reactions.

Which of the following stat tests is typically collected in a lithium heparin tube?

electrolyte panel, BMP

Identify the tubes needed to collect a CBC, Type & Cross and STAT potassium by color and in the proper order of collection for a multi tube draw:

green top (STAT) lavender top (CBC) pink top (Type & Cross)

What are the 2 blood samples that need to kept on ice? Why?

grey and green grey for lactic acid and green for ammonia *green wont ALWAYS be kept on ice, only when drawing for ammonia* This prevents breakdown of the cells in the tube

What is the number one task that a healthcare worker should perform before and after any task or care they provide?

hand hygiene

Which of the following additives is most commonly used for chemistry tests?

heparin

The nurse has initiated a 20-gauge peripheral IV catheter in the client's left cephalic vein using aseptic technique. The nurse is preparing to hang 1 liter of normal saline with 40 mEq (40 mmol) potassium chloride to infuse at 75 mL/hr beginning at 10:00 a.m. What information will the nurse include on the time strip being attached to the IV fluid container?

initiated at 10:00 a.m. today's date client's name normal saline with 40 mEq (40 mmol) potassium chloride ***REMEMBER: THIS IS DIFFERENT THAT THE LABEL ON THE IV INSERTION SITE***

Air embolism

is air in the circulatory system caused by a break in the IV system above the heart level. -characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

This tube color will indicate that the tube contains ethylenediaminetetraacetic acid (EDTA--edta is a chemical that binds and holds on to (chelates) minerals and metals such as chromium, iron, lead, mercury, copper, aluminum, nickel, zinc, calcium, cobalt, manganese, and magnesium. when they are bound, they can't have any effects on the test)?

lavendar

Identify the tubes needed to collect a PT/INR, Lactic acid, CBC, and BMP in the proper order of collection?

light blue (PT/ INR) green top (BMP) lavender top (CBC) grey top (Lactic Acid)

Which of the following stopper colors identifies a tube used for coagulation testing?

light blue Top

The blood to additive ratio is most critical for a specimen collected in this tube?

light blue top

What information should be included in documentation for IV insertion?

location where the IV access was placed size of the IV catheter or needle type of IV solution rate of the IV infusion the use of a securing or stabilization device the condition of the site patient's reaction to the procedure & pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

Describe infiltration

occurs when the IV cannula dislodges or perforates the wall of the vein. Characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and significant decrease in the flow rate

The purpose of sodium citrate in specimen collection is to?

protect coagulation factors

erythema

superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

Infiltration

the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. -characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate.

What are priority actions a nurse should take when infiltration is suspected?

the infusion should be stopped, the IV catheter discontinued, and a sterile dressing applied to the site after careful inspection to determine the extent of infiltration. The infiltration of any a mount of blood product, irritant, or vesicant is considered the most severe.