A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.

A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.

B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.

D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.

D. The nurse should promptly notify the healthcare provider to discuss the allergy history and request an alternative antibiotic that is not structurally related to penicillin or cephalosporins. Examples of alternative antibiotics may include antibiotics from different classes such as macrolides or fluoroquinolones, depending on the indication and sensitivity profile.

A. Diphenhydramine (Benadryl) is an antihistamine that can help manage allergic reactions. However, it should not be used as a standalone precautionary measure for a client with a history of anaphylaxis to penicillin. Anaphylaxis is a severe allergic reaction that can lead to life-threatening symptoms such as difficulty breathing, swelling, and low blood pressure.

B. Before taking any further steps, the nurse should clarify and confirm the nature and severity of the client's allergic reaction to penicillin. Anaphylaxis is a serious allergic reaction characterized by rapid onset and potentially life-threatening symptoms. Clarifying the history ensures accurate decision- making regarding the administration of cephalexin.

C. This is not recommended without further clarification and assessment. Given the history of anaphylaxis to penicillin, there is a significant risk of cross-reactivity with cephalosporins like cephalexin. Cephalosporins have a structural similarity to penicillin and can provoke allergic reactions in individuals with penicillin allergy, including anaphylaxis.