The nurse is preparing to administer an intravenous vesicant medication to a client. Which of the following findings should the nurse identify as a complication of extravasation?

Choice A reason: Increased respiratory rate suggests persistent respiratory distress or ineffective airway clearance in pneumonia, as the body compensates for hypoxia or hypercapnia. This indicates ongoing secretions or inflammation, not a therapeutic response, making it an incorrect indicator compared to clear lung sounds.

Choice B reason: Clear lung sounds indicate effective airway clearance in pneumonia, as treatments like antibiotics and chest physiotherapy reduce secretions and inflammation, allowing normal air movement. This reflects resolved airway obstruction and improved gas exchange, making it the best indicator of a therapeutic response to treatment.

Choice C reason: Brisk capillary refill reflects adequate peripheral perfusion but is unrelated to airway clearance in pneumonia. It does not indicate resolution of secretions or improved lung function, making it an irrelevant marker for evaluating treatment response compared to clear lung sounds, which directly assess airway patency.

Choice D reason: Decreased pleuritic pain suggests reduced pleural inflammation but does not confirm airway clearance. Pain reduction may occur without clearing secretions, the primary issue in pneumonia. Clear lung sounds better indicate successful treatment by demonstrating unobstructed airways and improved respiratory function.

Choice A reason: A basic metabolic panel assesses electrolytes and renal function but does not identify the bacterial cause of pneumonia. It supports overall patient status but does not guide antibiotic selection, making it less critical than sputum culture for ensuring targeted, effective antibiotic therapy.

Choice B reason: Sputum culture and sensitivity identify the specific bacteria causing pneumonia and their antibiotic susceptibilities, ensuring targeted therapy. Inappropriate antibiotics risk treatment failure and resistance. Obtaining the culture before antibiotics prevents false-negative results, making this critical for effective treatment.

Choice C reason: A chest radiograph confirms pneumonia’s presence and extent but does not identify the causative organism or antibiotic sensitivity. It supports diagnosis but does not guide specific antibiotic therapy, making it less critical than sputum culture for ensuring appropriate treatment.

Choice D reason: A complete blood count with differential shows infection severity (e.g., elevated white cells) but does not identify specific bacteria or antibiotic sensitivity. It supports diagnosis but is secondary to sputum culture, which ensures targeted antibiotic selection for effective pneumonia treatment.