Comprehensive Nursing Pharmacology Q 265
The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse’s immediate action?
A. Stomatitis lesion in the mouth.
B. Severe nausea and vomiting.
C. Complaints of pain at the site of infusion.
D. A rash on the client’s extremities.
Correct Answer: C. Complaints of pain at the site of infusion.
A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants that cause pain along the vein wall, with or without inflammation.
Option A: Platinum compounds have been classified as irritants. Oxaliplatin has been recently reported to have vesicant properties. Extravasation usually begins with a palpable swelling and discomfort upon palpation. Lesions usually progress to erythematous painful lesions and resemble erysipelas.
Option B: Nausea and vomiting can start within the first few hours after chemotherapy drugs are given and usually last about 24 hours. However, nausea and vomiting may start more than 24 hours after treatment and last several days (called delayed nausea and vomiting). Some people may have anticipatory nausea after having a few treatments, where they feel nauseated even before treatment is given because they expect to be sick.
Option D: Taxanes, including docetaxel and paclitaxel, are most often classified by literature as vesicants although there is no clear delineation. Most reactions following the extravasation of taxanes consist of erythema, tenderness, and swelling.