# A nurse caring for a client in septic shock notes that a peripheral IV in the left forearm — through which norepinephrine 8 mcg/min is infusing — is now cool, pale, swollen, and tender, and the IV pump alarms occlusion. Which sequence of actions by the nurse is most appropriate? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=374942&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PA ## Question A nurse caring for a client in septic shock notes that a peripheral IV in the left forearm — through which norepinephrine 8 mcg/min is infusing — is now cool, pale, swollen, and tender, and the IV pump alarms occlusion. Which sequence of actions by the nurse is most appropriate? ## Option 1. Immediately increase the norepinephrine infusion rate by 2 mcg/min to maintain cerebral and renal perfusion, then pause the infusion and flush the peripheral IV with 10 mL of normal saline to dilute and disperse the extravasated medication; afterward, remove the catheter, document the intervention, and reattempt the infusion in a new site once the swelling resolves. 2. Stop the norepinephrine infusion immediately, leave the catheter in place to aspirate residual drug, elevate the extremity, mark the area, notify the provider, prepare phentolamine 5-10 mg in 10 mL normal saline for subcutaneous infiltration around the extravasation site, and obtain a new central or large proximal IV access for resumed pressor therapy. **✔ Correct answer** 3. Leave the infusion running at the same rate, apply a cold pack to the site for 20 minutes to reduce edema, then attempt to flush the catheter with heparinized saline; if resistance persists, document the event and request a new peripheral IV placement in the same extremity distal to the original site. 4. Discontinue the infusion and remove the peripheral IV catheter, apply direct pressure to the site for 10 minutes, then place a warm compress to encourage absorption; after 15 minutes, restart the norepinephrine at the previous rate through a new IV in the right forearm, and ensure the monitor alarms are silenced to reduce patient anxiety. **Correct answer: 2** ## Explanation Vasopressor extravasation — vesicant emergency Norepinephrine and other potent vasopressors are vesicant drugs: extravasation into subcutaneous tissue causes intense local vasoconstriction, ischemia, and tissue necrosis. Findings of cool, pale, swollen, tender skin around the IV with pump occlusion alarm strongly suggest extravasation. Standard nursing sequence: (1) Stop the infusion immediately. (2) Leave the catheter in place initially — aspirate any residual drug from the catheter and surrounding tissue per policy. (3) Elevate the extremity and mark the borders of the affected area. (4) Notify the provider at once. (5) Phentolamine 5-10 mg in 10 mL normal saline, subcutaneously infiltrated around the affected site (multiple small injections) is the standard antidote for catecholamine extravasation. It works by competitive alpha-adrenergic blockade and reverses local vasoconstriction. Topical nitroglycerin paste or terbutaline are alternatives in some protocols. (6) Establish a new IV — central line or large proximal vein; vasopressors should be administered through a central line whenever possible. If no central access yet, a temporary large proximal peripheral line may be used briefly per institutional protocol. (7) Document time, drug, dose, IV site, area marked, interventions, and patient response. Photograph if institutional policy permits. Ice is generally avoided for catecholamine extravasation (worsens vasoconstriction). Never restart in the same line, never increase the rate to compensate, never simply pull and apply pressure without phentolamine and provider notification. ## In-depth explanation Clinical reasoning summary Vasopressor extravasation — vesicant emergency Norepinephrine and other potent vasopressors are vesicant drugs: extravasation into subcutaneous tissue causes intense local vasoconstriction, ischemia, and tissue necrosis. Findings of cool, pale, swollen, tender skin around the IV with pump occlusion alarm strongly suggest extravasation. Standard nursing sequence: (1) Stop the infusion immediately. (2) Leave the catheter in place initially — aspirate any residual drug from the catheter and surrounding tissue per policy. (3) Elevate the extremity and mark the borders of the affected area. (4) Notify the provider at once. (5) Phentolamine 5-10 mg in 10 mL normal saline, subcutaneously infiltrated around the affected site (multiple small injections) is the standard antidote for catecholamine extravasation. It works by competitive alpha-adrenergic blockade and reverses local vasoconstriction. Topical nitroglycerin paste or terbutaline are alternatives in some protocols. (6) Establish a new IV — central line or large proximal vein; vasopressors should be administered through a central line whenever possible. If no central access yet, a temporary large proximal peripheral line may be used briefly per institutional protocol. (7) Document time, drug, dose, IV site, area marked, interventions, and patient response. Photograph if institutional policy permits. Ice is generally avoided for catecholamine extravasation (worsens vasoconstriction). Never restart in the same line, never increase the rate to compensate, never simply pull and apply pressure without phentolamine and provider notification. ## Related questions - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=en) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=en) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=en) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. 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