Question

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site?

A. Apply a cold compress.
B. Discontinue the infusion.
C. Slow the rate of infusion.
D. Check for a blood return.

Answer 1

The nurse's first action when the client reports burning at the site: B. Discontinue the infusion.

Step-by-step explanation:

When a patient reports a burning sensation at the site of an intravenous chemotherapy infusion, it is indicative of a possible extravasation, where the chemotherapeutic agent may have leaked into the surrounding tissue. The first action a nurse should take in this situation is to discontinue the infusion immediately to prevent further tissue damage. Continuing the infusion or simply slowing the rate could lead to more severe complications, such as tissue necrosis.

After stopping the infusion, the nurse should then assess the site further by checking for a blood return to confirm if extravasation has occurred. Depending on the protocol of the healthcare facility, subsequent actions might include applying cold or warm compresses, elevating the affected extremity, and administering antidotes or treatments specific to the type of chemotherapeutic agent that has extravasated. These steps are aimed at minimizing tissue damage and managing the extravasation effectively. The answer is option b.