Evolve HESI Practice Exam

What initial action should the nurse take when a client's normal saline infusion has infiltrated and they complain of extreme arm pain?

1. Notify the healthcare provider

2. Measure the pulse volume and capillary refill distal to the infiltration

3. Apply a warm compress to the area

4. Assess the extent of infiltration

The correct answer is: Measure the pulse volume and capillary refill distal to the infiltration

The most appropriate initial action in response to a normal saline infusion that has infiltrated and caused the client extreme arm pain is to measure the pulse volume and capillary refill distal to the infiltration. This step is crucial because it helps assess the circulation in the area affected by the infiltration. By measuring pulse volume and observing capillary refill time, the nurse can determine if there is adequate blood flow beyond the infiltrated site and assess for potential complications such as compartment syndrome or ischemia. Gathering this information is essential for making informed decisions about the next steps in care and intervention. Proper assessment ensures that the nurse can provide the healthcare provider with clear information on the condition of the limb, which is vital for any further treatment options that may be necessary. While notifying the healthcare provider, applying a warm compress, or assessing the extent of infiltration are important steps, they should follow the primary assessment of vascular status to ensure immediate safety and address any urgent issues regarding blood flow.