A nurse is assessing an IV site and suspects extravasation from a vesicant medication. Which assessment findings and/or supportive actions may be expected? (Select all that apply)

A. Skip manual checks since barcoding ensures accuracy: Barcoding significantly reduces errors but is not infallible. System errors, mislabeling, or scanning failures can occur, so skipping verification can compromise patient safety.

B. Use the barcoding system only for high-risk medications: Barcoding should be applied to all medications to ensure consistency and safety, not limited to high-risk drugs. Limiting its use increases the potential for errors with routine medications.

C. Rely solely on the barcoding system for verification: While barcoding aids in verification, nurses must also apply clinical judgment and confirm correct patient, medication, dose, route, and timing. Sole reliance on technology can miss errors the system does not detect.

D. Conduct a manual check of the medication with the MAR before administration to ensure the medications match: Performing a manual comparison between the medication and the MAR provides an additional safety layer. This step verifies that the correct drug, dose, and route are administered to the right patient, complementing the barcoding system.

A. Severe: The term “severe” describes the intensity or seriousness of an adverse reaction, not a reaction opposite to the intended therapeutic effect. It refers to magnitude rather than the direction of the response.

B. Allergic: An allergic reaction is an immune-mediated response to a medication, such as rash, anaphylaxis, or urticaria. It does not describe a response that produces effects opposite to the drug’s intended action.

C. Paradoxical: A paradoxical reaction occurs when a medication produces an effect opposite to that expected, such as a sedative causing agitation or insomnia. This response may be due to individual variation in metabolism, receptor sensitivity, or central nervous system effects.

D. Toxic: Toxicity refers to harmful effects caused by excessive drug levels or accumulation, leading to organ damage or systemic harm. Toxic effects may be exaggerated but are not inherently opposite to the intended therapeutic outcome.