During the administration of chemotherapy through a peripheral intravenous (PIV) line, a patient suddenly complains of severe burning pain at the infusion site. What is the nurse's most appropriate action?
Apply a warm compress to the site to alleviate pain
Reassure the patient that the sensation is normal and continue monitoring.
Stop the infusion and assess the site for signs of infiltration or extravasation.
Increase the infusion rate to minimize discomfort.
The Correct Answer is C
A. Applying a warm compress is not appropriate as an initial intervention when a patient reports sudden severe burning during chemotherapy infusion. The priority is to stop the infusion immediately and assess the site. In addition, the use of warm versus cold compresses depends on the specific chemotherapeutic agent involved. Some vesicants require cold compresses to limit tissue spread, while others require warmth to promote drug dispersion. Applying any compress before stopping the infusion and assessing the site could delay critical intervention and worsen tissue injury.
B. Severe burning pain at the IV site during chemotherapy administration is abnormal and highly suggestive of infiltration or extravasation, particularly with vesicant or irritant drugs. Reassuring the patient and continuing to monitor without action can result in progressive tissue damage, necrosis, blistering, infection, and potential loss of limb function. Prompt recognition and intervention are essential to prevent permanent injury.
C. Stopping the infusion immediately is the most appropriate and highest-priority nursing action. Sudden pain, burning, or swelling at the PIV site during chemotherapy strongly indicates possible infiltration or extravasation, which is considered an oncologic emergency. Stopping the infusion prevents further drug leakage into surrounding tissues and allows the nurse to assess the site for redness, swelling, blanching, or decreased blood return. Early intervention reduces the risk of severe tissue necrosis and long-term complications.
D. Increasing the infusion rate is dangerous and contraindicated. If infiltration or extravasation is occurring, a faster infusion would force more of the chemotherapeutic agent into the surrounding tissue, significantly worsening tissue injury and pain. This action directly contradicts safe chemotherapy administration practices and could lead to irreversible damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Fibromyalgia is a chronic pain syndrome characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances, but it is not directly associated with the autoimmune manifestations of rheumatoid arthritis or the presence of dry eyes and mouth.
B. Raynaud’s phenomenon involves episodic vasospasm of the fingers and toes, causing color changes and discomfort with cold exposure. While it can occur in autoimmune conditions, it does not explain the hallmark symptoms of dry eyes and dry mouth.
C. Osteoporosis is a skeletal complication that may develop in rheumatoid arthritis patients due to chronic inflammation, corticosteroid use, or decreased mobility. However, it does not present with sicca symptoms (dry eyes and mouth).
D. Sjogren’s syndrome is an autoimmune disorder that often occurs secondary to rheumatoid arthritis. It is characterized by exocrine gland dysfunction, leading to dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). Early recognition is important to prevent dental caries, oral infections, and ocular complications, and to manage systemic involvement appropriately.
Correct Answer is A
Explanation
Rationale:
A. A barium swallow study is the most appropriate diagnostic test for evaluating an esophageal stricture. During the procedure, the patient swallows a radiopaque barium solution, which coats the lining of the esophagus and allows visualization of narrowed areas, strictures, or motility abnormalities on X-ray. This test helps determine the location, length, and severity of the stricture, which is essential for planning interventions such as esophageal dilation, stenting, or surgery.
B. An electrocardiogram (ECG) assesses the electrical activity of the heart. While chest pain or discomfort can sometimes be mistaken for cardiac issues, an ECG does not provide any information about the structure or function of the esophagus. Ordering an ECG would not contribute to diagnosing or managing an esophageal stricture.
C. A complete blood count (CBC) evaluates red blood cells, white blood cells, and platelets to identify anemia, infection, or bleeding disorders. Although anemia could occur if a stricture leads to chronic bleeding, the CBC cannot detect the presence, severity, or location of an esophageal stricture. It is useful for overall health assessment but is not diagnostic for dysphagia.
D. Pulmonary function tests (PFTs) measure lung volumes, capacities, and airflow to assess respiratory function. PFTs are used for conditions such as asthma, COPD, or restrictive lung disease. They do not evaluate swallowing, esophageal anatomy, or strictures, and thus are irrelevant to the assessment of progressive dysphagia.
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