A nurse is monitoring a client who is receiving a vesicant for chemotherapy via an IV infusion and notices the client has developed extravasation. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Phenytoin is a primary anticonvulsantutilized for the management of generalized tonic-clonic seizures and complex partial seizures. It works by blocking voltage-gated sodium channels, thereby preventing the repetitive firing of neuronal action potentials that characterize seizure activity. Its role in neurological stabilizationis well-established, though it requires diligent monitoring of serum drug levels to ensure therapeutic efficacy.

Rationale:

A.Status asthmaticus is an acute, severe asthma exacerbation that does not respond to standard bronchodilator therapy and requires corticosteroids or oxygen. Phenytoin has no pharmacological role in the respiratory system or the treatment of bronchospasm. This condition is a medical emergency focused on ventilation and airway management rather than the control of neuronal electrical activity.

B.Status epilepticus is a life-threatening state of persistent seizure activity where phenytoin is frequently used as a secondary agent for long-term seizure control. Following the initial administration of benzodiazepines to stop the acute seizure, phenytoin provides the sustained neuronal stabilization needed to prevent recurrence. It is a cornerstone of emergency neurological protocols designed to protect the brain from metabolic exhaustion.

C.A kidney transplant requires the lifelong administration of immunosuppressant medications, such as cyclosporine or tacrolimus, to prevent organ rejection. Phenytoin is not an immunosuppressant and actually has significant drug interactions that could lower the levels of transplant medications. Using phenytoin in this context would be inappropriate and potentially detrimental to the survival of the transplanted organ.

D.Endocarditis is a microbial infection of the heart valves or endocardium that necessitates prolonged courses of high-dose intravenous antibiotics. Phenytoin does not possess antimicrobial properties and cannot treat the underlying infection in endocarditis. While a patient with endocarditis might have a seizure due to an embolic stroke, the indication for phenytoin remains seizure management, not the heart condition.

The client presents with hypoglycemia (capillary glucose 64 mg/dL), hypotension (90/70 mm Hg), tachycardia, and fever. They are scheduled to receive both metoprolol and insulin aspart, which can further lower heart rate, blood pressure, and glucose levels. Priority nursing care requires immediate correction of life-threatening metabolic instability before administering medications that may worsen the condition.

Rationale:

• Capillary glucose: The capillary glucose of 64 mg/dL indicates hypoglycemia, which is an immediate priority because it can rapidly progress to neurological impairment, seizures, or loss of consciousness. Insulin aspart is scheduled for administration, but giving insulin in the presence of low blood glucose would worsen hypoglycemia. The nurse must first address and correct the glucose level to prevent acute neurological deterioration. Stabilizing blood sugar takes precedence over other abnormal findings in this scenario.

• Blood pressure: The blood pressure of 90/70 mm Hg indicates hypotension, which may compromise tissue perfusion to vital organs such as the brain, heart, and kidneys. Metoprolol is a beta-blocker that can further lower blood pressure and heart rate, increasing the risk of hemodynamic instability. After correcting hypoglycemia, blood pressure must be addressed to ensure safe medication administration.

• Reported pain: A pain level of 4/10 is considered mild to moderate and is not the highest priority in this situation. Although pain management is important, it does not pose an immediate threat to life compared to hypoglycemia or hypotension. The client’s metabolic and cardiovascular instability must be corrected first before addressing comfort measures. Pain can be reassessed and treated after stabilization.

• Temperature: The elevated temperature of 38.2°C (100.8°F) reflects an infectious process consistent with pneumonia, but it is not the most immediate life-threatening concern. Fever contributes to increased metabolic demand but does not require urgent correction before hypoglycemia or hypotension. Antipyretics and antibiotic therapy can address this once the client is hemodynamically stable. Priority remains with glucose and perfusion issues.

• Heart rate: The heart rate of 104/min is mildly elevated and likely secondary to fever, infection, or hypoglycemia. While it requires monitoring, it is not as critical as the low blood glucose or low blood pressure in terms of immediate risk. Tachycardia is compensatory and should not be treated in isolation. Addressing underlying instability will normalize the heart rate.