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    RN Comprehensive predictor 2023 proctored exam

    A nurse is caring for a client who is receiving a continuous intravenous infusion containing a vesicant that has become infiltrated. Which of the following actions should the nurse take first in treating this condition?

    Explanation & Rationale

    A. Start another IV line in another extremity: Establishing a new IV line is necessary to continue therapy, but it is not the first action. Immediate steps must focus on preventing further tissue damage from the infiltrated vesicant. B. Apply a warm, moist compress: Warm or cold compresses may be applied depending on the type of vesicant and institutional protocol, but this is a secondary intervention after stopping the infusion and protecting the tissue. C. Disconnect IV tubing and aspirate medication from the IV catheter: Aspirating the remaining medication may help reduce tissue exposure, but it is performed after the infusion is stopped to prevent further infiltration. D. Stop the infusion: Stopping the infusion immediately is the first and most critical action to prevent further tissue damage. Halting the delivery of the vesicant stops the source of injury and allows subsequent interventions to minimize local tissue necrosis.

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