Nokea
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
Correct Answer: A
Rationale: Chemotherapy drugs administered via peripheral IV can be vesicants, meaning they can cause severe tissue damage if they leak (extravasate) into surrounding tissues. Peripheral lines are more prone to this than central lines due to smaller vein size and less secure placement. Assessing the IV site hourly or per facility policy is the most important action to prevent extravasation, ensuring the line remains patent and no swelling, redness, or pain develops. Early detection allows prompt intervention, like stopping the infusion, to minimize harm. Educating about side effects and monitoring for nausea are key aspects of care but address systemic effects, not the immediate risk of local tissue injury. Warm packs might soothe discomfort but could worsen damage if extravasation occurs. Prioritizing IV site assessment reflects the nurse's role in safety and prevention, critical in oncology where chemotherapy's potency demands vigilant monitoring to protect the client from serious complications.