The nurse is administering promethazine via an IV pump and notices that the IV has infiltrated and the patient reports a burning sensation at the injection site.

What should be the nurse’s priority action?

Choice A rationale
While continuous pulse oximetry can provide useful information about a patient’s oxygen saturation levels, it is not the most crucial step before administering amphotericin B. Amphotericin B is an antifungal medication used to treat serious, potentially life-threatening fungal infections. It does not directly affect oxygen saturation levels.
Choice B rationale
The rate at which amphotericin B is administered can be important, as the medication must be given slowly through an IV infusion, which can take from 2 to 6 hours to complete. However, setting the IV pump to deliver the medication over a specific span of time is not the most crucial step before administration.
Choice C rationale
Continuous cardiac monitoring can be important in certain situations, but it is not the most crucial step before administering amphotericin B. While amphotericin B can cause some side effects related to the heart, such as changes in heart rate or blood pressure, these are not typically the primary concerns before administration.
Choice D rationale
Evaluating the patient’s sodium and calcium levels is the most crucial step before administering amphotericin B. Amphotericin B can cause changes in electrolyte levels, including sodium and calcium. Monitoring these levels can help prevent potential complications, making this the most crucial step before administration.

Choice A rationale
Infusing the medication slowly over a period of 60-90 minutes is a common practice for many intravenous medications to prevent adverse reactions. However, this is not the first step a nurse should take before administering intravenous acyclovir.
Choice B rationale
While diluting certain medications in a liter of normal saline can be a part of the preparation process, it is not the first step a nurse should take before administering intravenous acyclovir.
Choice C rationale
Checking the intravenous site for any signs of redness, heat, or swelling is the correct first step before administering any intravenous medication. This is to ensure that the IV site is not infected or inflamed, which could lead to complications such as phlebitis or infiltration.
Choice D rationale
Examining the patient for any open herpetic lesions is important when administering acyclovir, as the medication is used to treat herpes infections. However, this is not the first step a nurse should take before administering the medication.