A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
a. Assessing the IV site every hour
b. Educating the client on side effects
c. Monitoring the client for nausea
d. Providing warm packs for comfort
ANS: A
Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further.
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