An IV cannula site becomes cool, pale and swollen while the infusion is running. Which action should the nurse take first?
Correct answer: B. Stop the infusion and remove the cannula
- A. Slow the infusion and reassess the site
- B. Stop the infusion and remove the cannula
- C. Apply heat and continue the infusion
- D. Flush the cannula with normal saline
Explanation
These findings indicate infiltration, so the nurse stops the infusion and removes the cannula to prevent further leakage into tissue. Flushing or continuing the infusion can increase tissue injury; a new site is selected if therapy is still required.
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About IV Fluids and Blood Transfusion
IV therapy covers crystalloid and colloid fluids, electrolyte replacement, maintenance and resuscitation fluids, infusion equipment and complications such as infiltration, phlebitis, fluid overload and electrolyte imbalance. Blood transfusion content includes compatibility, cross matching, administration precautions and recognition of haemolytic, febrile and allergic reactions, distinct from ordinary IV fluid reactions.
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