Pharmacology IV Therapy #1

Question

Which action should the nurse perform first when a client reports pain at the intravenous (IV) site that is infusing a vesicant solution?

Answers

  1. Flush the site with 0.9% normal saline
    • Rationale:

      This is not the correct answer because the first nursing action in this scenario would be to stop the infusion. If the vesicant has leaked out into the tissue, the IV solution should be totally withdrawn from the IV cannula and the IV should be removed. The healthcare provider would be contacted and may order reversal agents to be injected around the site.

  2. Assess the site for signs of necrosis
    • Rationale:

      This is not the correct answer because the first nursing action in this scenario would be to stop the infusion. Then careful assessment of the site should occur. If the vesicant has leaked out into the tissue, the IV solution should be totally withdrawn from the IV cannula and the IV should be removed. The healthcare provider would be contacted and may order reversal agents to be injected around the site.

  3. Stop the infusion upon entry to the room
    • Rationale:

      This is the correct answer because if a client reports pain at the IV site infusing a vesicant solution, the nurse should immediately stop the infusion, then assess. This action is important because a vesicant can quickly cause extravasation. This is an IV complication which can cause skin blistering, sloughing, and necrosis at and around the IV site.

  4. Initiate reversal agents around IV site
    • Rationale:

      This is not the correct answer because the first nursing action in this scenario would be to stop the infusion. If the vesicant has leaked out into the tissue, the IV solution should be totally withdrawn from the IV cannula and the IV should be removed to prevent further damage to the tissue. Then, the healthcare provider would be contacted and may order reversal agents to be injected around the site.

Overview

A vesicant solution can cause significant tissue damage if it leaks into the surrounding tissue, including tissue death or necrosis. The nurse should know emergency actions when potential leaking is suspected. The priority is to stop the infusion from leaking more damaging solution.

Explanation

Learning Outcomes

Infusion of a vesicant solution requires keen nursing skills and critical thinking. If a client reports pain at the IV site, the nurse should immediately stop the infusion, then assess. This action is important because a vesicant can quickly cause extravasation. This is an IV complication which can cause skin blistering, sloughing, and necrosis at and around the IV site.

Test Taking Tip

Nursing students should focus studies on prioritizing actions, specifically, what to do first. Generally NCLEX wants to know if you can critically think before calling a provider, in case that is a necessary step for the welfare of the client.

Video Rationale