A client's infusion of normal saline infiltrated e...

Hesi Fundamentals Practice Test

Question Number 28

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take?

A. Ask about any past history of drug abuse or addiction.

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

C. Compress the infiltrated tissue to measure the degree of edema.

D. Evaluate the extent of ecchymosis over the forearm area.

✔ Correct Answer:

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

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Hesi Fundamentals Practice Test

Question Number 28

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