A nurse is preparing to administer an anti-anxiety medication to a patient prior to an MRI. Which type of medication order is this an example of?

A. Flush the IV catheter with saline to check patency: Flushing the catheter in the presence of swelling, pallor, and discomfort risks worsening infiltration or extravasation. Patency should not be tested when signs of tissue injury are present.

B. Notify the provider without stopping the infusion: Continuing the infusion can cause further tissue damage or complications. Immediate action to stop the infusion is required before contacting the provider.

C. Stop the infusion immediately and report to the physician: Swelling, pallor, and pain indicate infiltration or extravasation. The first priority is to stop the infusion to prevent further tissue injury, followed by assessment, documentation, and notification of the provider.

D. Increase the rate of infusion: Increasing the infusion rate would exacerbate tissue damage and is contraindicated in the presence of infiltration or extravasation.

A. Blistering or ulceration near the insertion site: Vesicant extravasation causes tissue injury due to leakage of the drug into surrounding tissue. Local findings may include blistering, ulceration, swelling, erythema, and pain at or near the IV site. These changes reflect direct cellular damage and require immediate intervention.

B. Notifying the provider promptly: Extravasation of a vesicant is a medical urgency that requires provider notification for further management. Specific antidotes, imaging, or surgical consultation may be indicated depending on the drug involved. Timely communication helps limit tissue necrosis and long-term complications.

C. Stopping the infusion immediately: Immediate discontinuation of the infusion prevents further leakage of the vesicant into surrounding tissue. The IV catheter is typically left in place initially to allow aspiration of the drug or administration of an antidote if prescribed. This step is critical to reduce the extent of tissue injury.

D. Continuing infusion at a slower rate: Slowing the infusion allows continued exposure of tissue to the vesicant and increases the risk of severe injury. Vesicant extravasation requires cessation, not adjustment, of the infusion rate

E. Continue infusion with no action: Failure to intervene allows ongoing tissue damage and increases the risk of necrosis, infection, and loss of function. Vesicant extravasation requires immediate assessment and intervention. No-action approaches are inappropriate and dangerous.