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    Hesi Med Surg Proctored Exam 1

    Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

    Explanation & Rationale

    Choice A rationale Keeping the head of the bed elevated until the treatment is completed is not typically recommended to reduce the risk of vesicant extravasation during intravenous chemotherapy. Choice B rationale Instructing the client to drink plenty of fluids during the treatment does not directly reduce the risk of vesicant extravasation. Hydration can help maintain good vein health, but it does not prevent extravasation. Choice C rationale Monitoring the client’s intravenous site hourly during the treatment is a key action to reduce the risk of vesicant extravasation. Regular monitoring allows for early detection of any signs of extravasation, such as swelling or redness at the IV site. Choice D rationale Administering an antiemetic before starting the chemotherapy can help manage side effects such as nausea and vomiting, but it does not reduce the risk of vesicant extravasation.

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