A patient receiving an IV infusion reports pain and burning at the cannula site, but the skin is neither pale nor swollen. Which finding should make the nurse suspect extravasation of a vesicant drug rather than simple infiltration?
Correct answer: C. Burning pain with blister formation
- A. Cool swelling around the cannula
- B. Blanching of the surrounding skin
- C. Burning pain with blister formation
- D. A slower flow through the tubing
Explanation
Burning pain with blistering suggests tissue injury from extravasation of a vesicant and requires immediate action according to the drug protocol. Cool swelling and slow flow are more typical of infiltration of nonvesicant fluid into surrounding tissue.
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About IV Fluids and Blood Transfusion
IV therapy covers crystalloid and colloid fluids, electrolyte replacement, maintenance and resuscitation fluids, infusion equipment and complications such as infiltration, phlebitis, fluid overload and electrolyte imbalance. Blood transfusion content includes compatibility, cross matching, administration precautions and recognition of haemolytic, febrile and allergic reactions, distinct from ordinary IV fluid reactions.
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