Key Takeaway
The most important IV therapy skill isn't insertion — it's monitoring. Recognizing complications early (infiltration, phlebitis, air embolism) and responding correctly is what the NCLEX tests and what protects your patients.
IV Site Selection
Choose the most distal site first and work proximally. Avoid the antecubital fossa when possible — it limits mobility and is prone to positional occlusion. Never use an extremity with lymphedema, AV fistula, or on the affected side of a mastectomy.
| Site | Gauge | Best For | Notes |
|---|---|---|---|
| Forearm (cephalic, basilic) | 18–20G | General IV access, blood transfusions, most medications | First choice for most patients — stable, accessible |
| Antecubital fossa | 18–20G | CT contrast, rapid fluid resuscitation, blood draws | Use only when other sites unavailable — limits arm movement |
| Hand (dorsal metacarpal) | 20–22G | Maintenance fluids, non-irritating medications | More painful to insert; avoid vesicants |
| External jugular (EJ) | 16–18G | Emergency access when peripheral sites unavailable | Requires physician or advanced practice order at most facilities |
IV Fluid Types: Tonicity & Clinical Use
Understanding tonicity is essential for selecting the right fluid and anticipating its effects on fluid distribution. This is a high-yield NCLEX topic.
Normal Saline (0.9% NaCl)
Clinical Use
Fluid resuscitation, blood transfusions, hyponatremia, medication dilution
Caution
Risk of hyperchloremic acidosis with large volumes; avoid in heart failure
Lactated Ringer's (LR)
Clinical Use
Burns, trauma, surgical patients, metabolic acidosis
Caution
Contains potassium — avoid in hyperkalemia and renal failure
D5W (5% Dextrose in Water)
Clinical Use
Medication dilution, hypoglycemia, free water replacement
Caution
Becomes hypotonic once dextrose metabolized — do not use for resuscitation
0.45% NaCl (½ NS)
Clinical Use
Cellular dehydration, hypernatremia, DKA maintenance
Caution
Can cause cellular swelling — avoid in head injury, hyponatremia
3% NaCl (Hypertonic Saline)
Clinical Use
Severe symptomatic hyponatremia, cerebral edema
Caution
Must be given via central line. Monitor sodium closely — rapid correction causes osmotic demyelination
IV Complications: Recognition & Immediate Action
These are the complications the NCLEX tests most frequently. For each one, know the signs, your immediate nursing action, and when to escalate.
Signs & Symptoms
Swelling, coolness, pallor, pain at site, slowed infusion rate
Nursing Action
Stop infusion immediately. Remove IV. Elevate extremity. Apply warm compress for non-vesicants.
Signs & Symptoms
Same as infiltration but with vesicant medication — blistering, tissue necrosis possible
Nursing Action
Stop infusion. Do NOT remove IV yet — aspirate residual drug first. Notify provider. Apply antidote per protocol.
Signs & Symptoms
Redness, warmth, pain, streak along vein, palpable cord
Nursing Action
Discontinue IV. Apply warm moist compress. Document and monitor. Restart in opposite extremity.
Signs & Symptoms
Sudden dyspnea, chest pain, hypotension, "mill wheel" murmur, altered consciousness
Nursing Action
Clamp tubing. Position patient left lateral Trendelenburg. Administer 100% O₂. Notify provider STAT.
Signs & Symptoms
Dyspnea, crackles, hypertension, JVD, peripheral edema, S3 heart sound
Nursing Action
Slow or stop infusion. Elevate HOB. Notify provider. Anticipate diuretics. Monitor I&O closely.
Signs & Symptoms
Fever, chills, erythema/purulence at site, positive blood cultures
Nursing Action
Remove IV. Obtain blood cultures. Notify provider. Anticipate antibiotics. Document.
High-Yield IV Therapy Facts for NCLEX
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