Management of Care Q 12

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During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is:

  

     A. Notify the physician.

     B. Flush the IV line with saline solution.

     C. Immediately discontinue the infusion.

     D. Apply an ice pack to the site, followed by warm compress.

    

    

Correct Answer: C. Immediately discontinue the infusion.

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Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complications.

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Option A: After discontinuing the infusion, the nurse should notify the physician.

Option B: Flushing may aggravate the edema since the IV cannula might be dislodged.

Option D: Compresses may be given as indicated by the physician.

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