Which of the following nursing intervention is NOT appropriate when an IV infusion infiltrates?

DSSSB - 28 August 2019 (Shift-1)

Medical Surgical Nursing

Easy

Appeared in: DSSSB - 28 August 2019 (Shift-1)

Explanation

Massaging or rubbing an infiltrated IV site is strictly contraindicated as a nursing intervention.
This action can cause further mechanical trauma to already fragile tissues, which can increase swelling and pain.
Rubbing the site can disperse the infiltrated fluid, potentially spreading it to a larger tissue area and increasing the risk of complications like compartment syndrome or tissue necrosis, especially if the fluid is a vesicant.
The key principle is to minimize further tissue injury, and massaging directly contradicts this.

Option A: This is an appropriate intervention. Elevating the affected limb helps reduce swelling by using gravity to facilitate the drainage and reabsorption of the infiltrated fluid back into circulation.
Option B: This is an appropriate intervention for most non-vesicant infiltrations. Applying a warm, moist compress promotes vasodilation, which increases blood flow to the area and helps the body absorb the excess fluid more quickly.
Option D: This is the first and most critical appropriate action. Immediately stopping the infusion prevents more fluid from leaking into the subcutaneous tissue, thus limiting the extent of the infiltration and potential damage.

Clinical Relevance

Nursing practice connection: Knowing Management of IV Infiltration helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
IV infiltration is a common complication of peripheral IV therapy. Prompt and correct nursing action is crucial for patient safety and comfort, preventing progression to more severe complications like tissue necrosis or compartment syndrome.
Nurses must perform regular (at least hourly) assessments of IV sites, checking for pain, swelling, coolness, and blanching. Patient education is also key, instructing them to report any discomfort at the IV site immediately.
Accurate documentation is essential, including the time the infiltration was noted, the appearance of the site, the nursing interventions performed (e.g., stopped infusion, elevated limb), and the patient's response.

How to Approach the Question

First, identify the negative framing of the question: 'NOT appropriate'. This means you are looking for the incorrect action among the options.
Mentally review the standard protocol for managing IV infiltration: Stop, Elevate, Apply Compress, Document.
Evaluate each option against this protocol.
Option A (Elevating): This is a correct action to reduce swelling.
Option B (Warm compress): This is a correct action to promote fluid absorption.
Option D (Stopping infusion): This is the priority correct action.

Concept Tested & Keywords

Concept Tested: Management of IV Infiltration
Stem keywords: IV infusion, infiltrates, nursing intervention
Lead-in keywords: NOT appropriate
Negative lead-in flag: The question asks for the intervention that is NOT appropriate, meaning three of the options are correct nursing actions.