Of 400 Verified Questions and Answers), Complete
Solution Guide With Rationale, Latest 2022
Compilation.
SAMPLE
Question: A nurse is caring for a client who is receiving an intravenous (IV) infusion of an
antineoplasticmedication. During the infusion, the client complains of pain at the insertion site.
During an inspection of the site, the nurse notes redness and swelling and that the rate of infusion
of the medication has slowed. The nurse should take which appropriate action?
1.Notify the registered nurse.
2.Administer pain medication to reduce the discomfort.
3.Apply ice and maintain the infusion rate, as prescribed.
4.Elevate the extremity of the IV site, and slow the infusion.
Answer: 1. Notify the registered nurse
Rationale:
When antineoplastic medications (Chemotheraputic Agents) are administered via IV, great care
must be taken to prevent the medication from escaping into the tissues surrounding the injection
site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of
extravasation, such as redness or swelling at the insertion site and a decreased infusion rate. If
extravasation occurs, the registered nurse needs to be notified; he or she will then contact the
health care provider.