Place the nursing actions in order when an antineoplastic vesicant is suspected of extravasating from a peripheral IV.
Ordered Response
Choose your responses, then check the answer.
Explanation
Stop the vesicant while preserving access for aspiration. Do not flush medication farther into tissue. Escalate for the drug-specific antidote and compress, remove the device when directed, and complete measurement, documentation, teaching, and follow-up.
Correct sequence Stop and leave access → aspirate without flushing → identify drug and activate protocol → apply drug-specific treatment → document and follow.
Why this is correct Leaving the catheter initially permits aspiration of residual vesicant and, for some agents, antidote delivery. Flushing can spread the drug through tissue. Compress type, antidote, device removal, and escalation depend on the specific agent and location, so the protocol and pharmacy or oncology team are engaged early.
NCLEX decision rule With suspected extravasation, the universal first actions are to stop the infusion and avoid flushing; the rest is drug specific.
Reference
1ONS/ASCO 2025 extravasation guideline summary
Suspected vesicant extravasationDuring infusion, the client reports burning. The site is swollen and has no blood return. Use the current drug-specific extravasation protocol and avoid flushing the device.
Vesicant — A drug capable of causing tissue necrosis or severe injury if it escapes the vein.
Extravasation — Leakage of a vesicant or irritant with vesicant properties into surrounding tissue.
Antidote — A drug-specific treatment that may reduce tissue injury.