A licensed practical nurse (LPN) notes a small area of swelling at the IV site of a patient receiving a vesicant chemotherapy agent. What is the nurse's priority action to prevent tissue damage?
Immediately remove the IV catheter without withdrawing the solution.
Administer an antidote through the same IV line before removing the catheter.
Withdraw the solution from the IV catheter before removing it.
Elevate the affected extremity and apply warm compresses before stopping the infusion
The Correct Answer is C
Rationale:
A. Removing the catheter without first aspirating the vesicant allows the drug to remain in the tissue, increasing the risk of severe local tissue necrosis. This is not the recommended first action.
B. Some vesicant extravasations do require antidote administration, but the antidote is not always given through the IV line itself and typically after the solution is aspirated. Administering through the IV without removing the drug from the tissue first can worsen tissue injury.
C. The priority action is to stop the infusion and carefully aspirate any residual vesicant from the catheter before removing it. This minimizes the amount of vesicant that enters surrounding tissue, reducing necrosis, blistering, and long-term damage. After aspiration, the nurse follows facility protocol for antidote administration, compression (warm or cold depending on the drug), and site monitoring.
D. While elevation and warm or cold compresses are part of post-extravasation care, they are secondary interventions. The priority is to stop the infusion and remove as much vesicant as possible to prevent further tissue injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Some mild protrusion of a stoma can be normal postoperatively, depending on the type of colostomy. Unless it is excessive, painful, or associated with other complications, it is not immediately alarming.
B. These vital signs indicate possible early infection or systemic response. A slightly elevated temperature and tachycardia 3 days post-surgery can suggest surgical site infection or intra-abdominal complication, and the elevated blood pressure could indicate pain or stress response. This finding must be reported and documented promptly for early intervention.
C. Green-brown liquid drainage is normal for colostomy output, especially in the early postoperative period. Minor oozing from the pouch edges may indicate minor skin irritation, which is common and does not require urgent reporting.
D. Mild swelling, redness, and a small amount of bleeding at the stoma base are common in the immediate postoperative period due to surgical trauma. While it should be monitored, it is not as urgent as systemic signs like abnormal vital signs.
Correct Answer is D
Explanation
Rationale:
A. A healthy stoma is not typically painful, even postoperatively. Patients may experience mild discomfort from surgery, but the stoma itself has no nerve endings and should not cause significant pain. Persistent pain could indicate complications such as ischemia or infection.
B. A purple stoma indicates poor blood supply or ischemia, which is an emergency. A normal stoma should be beefy red, moist, and slightly protruding, indicating adequate perfusion.
C. The consistency of stool depends on the location of the colostomy. A sigmoid colostomy, being located in the lower part of the colon, generally produces formed stool rather than liquid output. This is in contrast to ascending or transverse colostomies, where output may be more liquid.
D. A sigmoid colostomy is surgically placed in the left lower quadrant of the abdomen, which is consistent with the location of the sigmoid colon. Educating the patient about stoma location helps with self-care, appliance placement, and expectations postoperatively.
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