Question

Prior to administering mechlorethamine, the nurse notes a loss of blood return via a 24-gauge peripheral line. What is the nurse's priority action?

a) Request a central line placement.
b) Flush the line, then administer the medication.
c) Administer the medication as scheduled.
d) Document the observation and continue with the administration.

Answer 1

The nurse's priority action would be to request a central line placement.

Step-by-step explanation:

The nurse's priority action would be to request a central line placement (option a). In this situation, a loss of blood return through a peripheral line could indicate a possible occlusion or clot in the line, which could prevent the medication from reaching the bloodstream effectively. A central line provides direct access to large veins and allows for rapid administration of medications without the risk of an occlusion.

Administering the medication as scheduled (option c) or flushing the line (option b) would not address the issue of the loss of blood return. Continuing with the administration without addressing the issue could pose a risk to the patient's health.

Documenting the observation and continuing with the administration (option d) without taking any further action to ensure proper medication administration would not be appropriate in this case.