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 A
Explanation
Rationale:
A. Alcohol and caffeine are well-known risk factors that worsen GERD symptoms. Both substances can decrease lower esophageal sphincter (LES) tone, allowing gastric contents to reflux into the esophagus. They can also increase gastric acid secretion and irritate the esophageal mucosa. Teaching clients to limit or avoid alcohol and caffeine is a key component of GERD education.
B. Lying down after eating does increase the risk of GERD symptoms. When a person lies flat, gravity no longer helps keep stomach contents in the stomach, making reflux more likely. Clients with GERD are advised to remain upright for at least 2–3 hours after meals and to elevate the head of the bed.
C. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the gastric and esophageal mucosa and may worsen GERD symptoms or increase the risk of gastrointestinal bleeding. Therefore, it is not advisable to take aspirin routinely if GERD is present unless specifically prescribed.
D. Mercury-containing foods, such as certain seafood, are not associated with GERD symptoms. Dietary triggers for GERD are related to acid production, LES relaxation, and mucosal irritation.
Correct Answer is B
Explanation
Rationale:
A. Advising the patient to use over-the-counter antidiarrheal medication may mask symptoms but does not address the underlying cause. If the diarrhea is due to an infection, particularly Clostridium difficile, using antidiarrheals could worsen the condition by retaining toxins in the colon.
B. Assessing the patient for signs of Clostridium difficile (C. difficile) infection is the priority. PPIs reduce gastric acidity, which can alter gut flora and increase susceptibility to C. difficile overgrowth, especially in patients with new-onset diarrhea and abdominal pain. Early recognition is critical to prevent severe colitis, dehydration, sepsis, or toxic megacolon. The nurse should monitor for frequent watery stools, fever, abdominal tenderness, and laboratory confirmation through stool testing.
C. Instructing the patient to discontinue the PPI immediately is not recommended without provider guidance. Abrupt cessation may worsen GERD symptoms, and the underlying cause of diarrhea must first be evaluated.
D. Recommending increased fiber intake may help manage some types of diarrhea, but in the presence of possible C. difficile infection, this approach is not appropriate and could exacerbate discomfort or bloating.
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