Difficulty: Medium
Average Score: 86%
Simulated
The nurse is caring for a client receiving an intravenous medication that is a vesicant. The IV flow has stopped and there is pain,burning and swelling at the IV site. What action should the nurse take first?
Correct answer
B
Rationale
The correct answer is B: Immediately remove the catheter. When a vesicant medication infiltrates, it can cause tissue damage leading to pain, burning, and swelling. Removing the catheter is crucial to prevent further damage. Elevating the extremity (A) or placing a cool compress (D) may not address the underlying issue. Keeping the catheter in place (C) can exacerbate tissue damage. Removing the catheter promptly is the priority to prevent complications.