If infiltration or phlebitis occurs, what should the nurse do immediately?

• A. Elevate the limb and apply ice
• B. Remove the IV device
• C. Apply warm compress and continue IV
• D. Notify the physician only

Answer: (B)

The immediate action is to stop the infusion and remove the IV cannula. When infiltration or phlebitis occurs, the first step is to discontinue the IV to prevent ongoing tissue injury from the IV solution or irritation of the vein. Once the cannula is out, you can assess the affected area, decide on the appropriate care (cold compress for infiltration to reduce edema, warm compress for phlebitis after initial cooling, elevation for swelling), and start a new IV at a different site if IV therapy is still needed. Delaying removal by continuing the IV or waiting for a physician can allow further damage and worsen outcomes.