Vesicant extravasation: stop the infusion immediately, leave the catheter, aspirate, and follow antidote protocol to prevent necrosis.
Before you read
Test yourself first: 5 questions
Question 1 of 5
When giving enoxaparin subcutaneously, the nurse should:
Answer: B. Inject into the abdomen ('love handles'), do NOT aspirate, do NOT expel the air bubble, and do not rub the site — to reduce bruising/hematoma.
Question 2 of 5
A nurse is preparing to administer enoxaparin subcutaneously. Which technique is correct?
Answer: B. Enoxaparin is given subcutaneously into the abdomen at least 2 inches from the umbilicus; the nurse should not expel the air bubble in the prefilled syringe and should not aspirate or rub the site afterward, as these actions increase bruising. The skin fold should be held throughout the injection.
Question 3 of 5
A 25 kg child is ordered a medication at 0.1 mg/kg/dose. What is the correct single dose?
Answer: B. 25 kg times 0.1 mg/kg equals 2.5 mg per dose. Careful decimal handling prevents a tenfold error (such as misreading as 25 mg).
Question 4 of 5
A nurse is teaching a client how to rotate insulin injection sites. What is the primary reason for rotating sites?
Answer: B. Rotating injection sites prevents lipohypertrophy (fatty lumps) and lipoatrophy, which can impair insulin absorption and cause erratic glucose control. Site rotation is not done to increase the dose, speed onset uniformly, or reduce the number of injections needed.
Question 5 of 5
A client is to receive negative-pressure wound therapy (wound vac). Which statement best describes how this therapy promotes healing?
Answer: A. Negative-pressure wound therapy applies controlled subatmospheric (negative) pressure to the wound, which removes excess exudate, reduces edema, increases local blood flow, and promotes the formation of granulation tissue. It is not used to cauterize tissue or deliver systemic antibiotics.
Keep the streak going with more questions like these, each with a full rationale.
What is iv therapy and site care?
Nursing care ensures patency, prevents complications (infiltration, phlebitis, infection), and protects the site. Key principle: assess the site every shift/before each use, and stop the infusion at the first sign of a complication.
Key points to remember
- Infiltration = a cool, pale, swollen site (fluid leaks into tissue); phlebitis = a warm, red, tender, cordlike vein (inflammation).
- Extravasation is infiltration of a vesicant drug and can cause tissue necrosis; stop infusion immediately and follow drug-specific protocol.
- Always verify a blood return and flush easily before administering medication.
- Rotate peripheral sites and change the dressing per policy; assess the site for redness, swelling, and drainage every shift.
- Use the smallest gauge that meets the therapy and choose the most distal suitable vein first.
- Air in the line and rapid/large air boluses risk air embolism; clear air from tubing before connecting.
Signs & symptoms
- Infiltration: cool, pale, swollen, no blood return
- Phlebitis: warm, red, hard cord, tender
- Extravasation = vesicant leak → tissue necrosis
Nursing priorities
- Assess the IV site for patency, infiltration, phlebitis, and infection before each use and routinely.
- Stop the infusion and discontinue the IV at the first sign of infiltration or phlebitis, then restart in a new site.
- Verify the right fluid/rate and check for blood return before giving IV medications.
- Maintain a clean/dry dressing and label tubing and site with date.
- Monitor for fluid overload (lung sounds, edema, weight) especially in older adults and heart/kidney clients.
Labs & values
Patient teaching
- Report pain, burning, swelling, redness, or leaking at the IV site right away.
- Avoid bumping or pulling on the IV and tell staff if the pump alarms.
- Keep the arm with the IV positioned to avoid kinking the line.
Red flags: report now
- Vesicant extravasation: stop the infusion immediately, leave the catheter, aspirate, and follow antidote protocol to prevent necrosis.
- Signs of fluid overload (dyspnea, crackles, JVD, sudden weight gain) require slowing the rate and notifying the provider.
- Fever, site redness with purulent drainage, or red streaking suggests infection/systemic spread; report.
References
Clinical references for this topic
