What action should the nurse take when an IV infusion is delivering and the IV site becomes cool, pale, and swollen?

• A. Stop the current infusion and change to another site.
• B. Slow down the rate of the infusion.
• C. Flush the IV line with normal saline.
• D. Retape the IV catheter to decrease the pressure

Answer: (A)

Recognizing infiltration from IV therapy is the key idea here. When fluid leaks into the surrounding tissue, the area often feels cool to the touch, looks pale, and swells. These signs mean the cannula is no longer in the vein, and continuing the infusion can worsen tissue damage.

The best action is to stop the infusion immediately and remove the IV catheter, then establish IV access at a new site. This prevents further leakage into tissue and preserves the integrity of the venous access. After removal, elevate the affected limb to help reduce swelling and assess the area for pain, capillary refill, and sensation. You can apply a cold compress initially to limit edema and tissue injury, then switch to warmth if recommended by facility policy after the first day. Document what you observed and continue to monitor the area; start a new IV somewhere else as needed.

Other options don’t address the problem: slowing the rate won’t stop leakage, flushing could push more fluid into tissue, and retaping doesn’t fix the underlying issue.