Which statement best describes signs of IV infiltration and the immediate action?

• A. Swelling at the site, cool/pale skin, pain or tightness; discontinue infusion, remove catheter, elevate limb.
• B. Redness at the IV site with warmth.
• C. Fever and chills; continue infusion.
• D. Cough and dyspnea; clamp line.

Answer: (B)

Infiltration happens when IV fluid leaks into the surrounding tissue, causing swelling at the insertion site with skin that feels cool or pale and a sense of tightness or pain as the tissue swells. The immediate action to take is to discontinue the infusion, remove the catheter, and elevate the limb to reduce swelling and help the leaked fluid be absorbed. Redness with warmth points more to phlebitis or local infection, which would lead to different management rather than treating infiltration. Fever and chills suggest a systemic issue, not infiltration, and coughing with dyspnea would raise concern for an air embolism or other serious reaction, requiring urgent assessment.