hard · NCLEX-RN pharmacology
A nurse is administering vincristine via a peripheral intravenous line to a client with lymphoma. During the infusion, the client reports localized pain and swelling at the insertion site, and the nurse suspects extravasation. Which actions should the nurse perform? Select all that apply.
- Apply a tight tourniquet proximal to the site to prevent systemic absorption of the drug.
- Apply a cold compress to the insertion site for 20 minutes to localize the drug.
- Stop the infusion immediately and leave the cannula in place for aspiration of residual drug.
- Flush the cannula vigorously with heparinized saline to clear any occlusion before aspiration.
- Elevate the affected extremity to promote lymphatic drainage and reduce edema.
- Administer the ordered antidote, hyaluronidase, subcutaneously around the extravasation site if prescribed.
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