Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 3==
A client receiving a norepinephrine infusion through a peripheral intravenous catheter reports burning at the site, and the nurse notes blanching and swelling around the insertion site. Which action should the nurse take '''first'''?
# Remove the catheter and apply a warm compress.
# Stop the infusion but leave the catheter in place.
# Elevate the extremity and continue the infusion at a slower rate.
# Apply a cold compress and reassess in 30 minutes.

'''Answer:''' 2 (B). Stop the infusion but leave the catheter in place.

''Rationale:'' Norepinephrine is a vesicant, so this is extravasation, not simple infiltration. The infusion is stopped immediately, but the catheter stays in place so residual drug can be aspirated and the antidote, phentolamine, can be infiltrated through it as ordered. Option 1 removes the access needed for the antidote and is the response to a nonvesicant infiltration. Option 3 continues tissue injury. Option 4 delays care, and with vasoconstrictor extravasation warmth and vasodilation, not cold, is the goal.