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A nurse is administering a vesicant chemotherapeutic agent. Which of the following actions is most important to protect the patient from extravasation?

Explanation

•The nurse should confirm that the IV is in the vein by checking for blood return. This confirms that the IV has not infiltrated, reducing the risk of the vesicant agent being delivered into the surrounding tissues.

•A vesicant is an agent that causes tissue irritation and possible tissue necrosis. Signs of extravasation (pain around infusion site) should be taken seriously because of the risk of tissue necrosis.

•If a vesicant agent infiltrates at an I.V. site, discontinue the I.V. immediately and remove the catheter. Get an order to place an ice pack on the site for 15 minutes, repeating this each hour for four hours.

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