Which action is last in the infiltration management sequence for a nonvesicant IV solution?

• A. Stop infusion and remove peripheral catheter
• B. Elevate the extremity
• C. Rate the infiltration using the INS Infiltration Scale and document procedure
• D. Apply a sterile dressing

Answer: (C)

Infiltration management follows a sequence where the most immediate action is to stop the infusion and remove the IV catheter, then elevate the limb to reduce swelling. The crucial final step is to evaluate how severe the infiltration is using a standardized tool and then document what you found. The INS Infiltration Scale gives an objective rating based on visible signs like swelling, pain, skin integrity, and progression, which guides subsequent care and ensures clear communication in the patient’s record. Documentation is essential for continuity of care, future assessments, and medicolegal purposes, so it logically comes last.

While applying a sterile dressing protects the site after care steps and elevating helps control edema, those actions occur earlier in the sequence or as ongoing care. Assessing the infiltration with the scale and recording the findings consolidates the evaluation and informs any further treatment or monitoring needed.