During an intravenous chemotherapy infusion, the patient reports burning at the cannula site, and the surrounding skin is swollen. What should the nurse do first?
Correct answer: A. Stop the infusion and leave the cannula in place
- A. Stop the infusion and leave the cannula in place
- B. Flush the cannula rapidly with normal saline
- C. Remove the cannula and apply firm pressure
- D. Apply heat before checking the infusion site
Explanation
Burning and swelling suggest possible extravasation. The nurse stops the infusion immediately but leaves the cannula in place so any residual drug can be aspirated or an antidote administered according to policy. Flushing may spread the drug into surrounding tissue.
Report an error
The more specific you are, the faster it gets fixed. A source beats an opinion.
Prefer email? support@testustad.com
About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
Practise Clinical Judgement and Prioritisation
50 free Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
Discussion
Stuck on an option, or know a faster way to get there? Ask or explain it here.
No comments yet. Be the first to explain this one.
Exams that ask International Nursing Practice questions like this
International Nursing Practice is on 2 papers prepared for on TestUstad, and all of them draw the same bank, so this question is worth knowing for every one of them.
More Clinical Judgement and Prioritisation questions
A patient receiving continuous bladder irrigation reports severe suprapubic pressure, and no drainage has entered the collection bag for 30 minutes. What should the nurse do first?
A patient begins having a generalised tonic-clonic seizure while sitting in a chair. What should the nurse do first?
A patient two days after abdominal surgery suddenly reports that the incision has opened, and loops of bowel are visible. Which action should the nurse take first?
A patient with a large gastrointestinal bleed is pale, clammy, and dizzy. The blood pressure is 82/48 mmHg, and the patient is becoming less responsive. What should the nurse do first?
A patient receiving intravenous potassium develops muscle weakness and the cardiac monitor shows widening QRS complexes. What should the nurse do first?
A patient who has recently delivered a baby has heavy vaginal bleeding and a soft, boggy uterus. What should the nurse do first?