Question

The nurse is monitoring the IV infection of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all.

A. Stop the infusion
B. Notify healthcare provider
C. Prepare to apply ice/heat to site
D. Restart IV at distal part of the same vein
E. Prepare to administer a prescribed antidote into the site
F. Increase flow rate of the solution to flush the skin and subcutaneous tissue

Answer 1

A nurse suspecting extravasation should stop the IV infusion, notify the healthcare provider, prepare to apply ice/heat to the site, and prepare to administer a prescribed antidote, but should not restart the IV in the same vein or increase the flow rate.

Step-by-step explanation:

When a nurse suspects extravasation of an antineoplastic medication during an IV infusion, indicated by the patient's pain at the insertion site, redness, swelling and a slowed infusion rate, certain immediate actions are warranted:

• A. Stop the infusion: This is the first step to prevent further leakage of the medication into the tissue.
• B. Notify healthcare provider: It is critical to quickly inform a healthcare provider about the situation so that appropriate action can be taken.
• C. Prepare to apply ice/heat to the site: Depending on the type of medication, ice or heat may be recommended to reduce the spread and help manage pain and swelling.
• E. Prepare to administer a prescribed antidote into the site: If available, an antidote may be administered to mitigate the effects of the extravasated medication.

Actions such as restarting the IV at a distal part of the same vein (D) and increasing the flow rate (F) would not be appropriate as they could worsen the situation and are not recommended actions when extravasation is suspected.