The nurse is caring for a patient receiving an antineoplastic medication IV. While the medication is infusing, the IV needle becomes dislodged and goes in to the tissue. What is the highest priority for this patient at this time?
a. Call the physician on call to report the occurrence.
b. Inject medication immediately into the skin to counter the effect of the medication.
c. Elevate the affected IV site and apply ice.
d. Place the affected site into a dependent position.
ANS: B
Some medications given intravenously will damage and destroy the tissues of the skin if the IV needle becomes dislodged and medication goes into the tissue and not the veins. This is called extravasation. Medication must be available that can be immediately injected directly into the skin to counter the effect of the antitumor medicine. Failure to act quickly may result in huge areas of tissue damage, sometimes destroying the ability of the hand or arm to function.
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