43. The correct nursing actions when administering a vesicant chemotherapeutic agent are to:
Select all that apply.
43. The correct nursing actions when administering a vesicant chemotherapeutic agent are to:
Select all that apply.
. Assess the site for swelling, redness, or presence of vesicles.
. Administer the drug by IV push.
. Give the drug slowly to minimize cardiac toxicity.
. Apply ice to the site if infiltration occurs.
. Apply heat to the site if extravasation occurs.
Test-Taking Tip
"Assess" and "heat" are the best answers.
Content Area: Adult Health, Oncological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Medication Administration
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Answer 1 is correct because these are local signs of tissue damage from infiltration of a vesicant, which causes blistering or necrosis with infiltration. Answer 2 is incorrect because IV push increases the chance of infiltration. Nonvesicants, which may cause little to no irritation if infiltration occurs, are given safely by IV push. Answer 3 is incorrect because not all vesicants are cardiotoxic. Answer 4 is incorrect because ice or a cold pack should not be used with vinca alkaloids. Answer 5 is correct because heat is specifically recommended to prevent ulceration with vincristine or vinblastine if extravasation of the drug occurs.