Place the actions in order when a client receiving an IV antibiotic develops stridor, wheezing, generalized hives, and a blood pressure of 76/42 mm Hg.
Ordered Response
Choose your responses, then check the answer.
Explanation
Remove the trigger, call for help, and assess the client immediately. Positioning and intramuscular epinephrine should not be delayed. Provide oxygen, airway readiness, and rapid IV crystalloid for shock, then monitor closely and repeat epinephrine or escalate support when prescribed. Antihistamines and corticosteroids are adjuncts and must not delay epinephrine.
Correct sequence Stop exposure and call → position for perfusion → IM epinephrine → oxygen, airway, and fluids → reassess and repeat or escalate.
Why this is correct Epinephrine is the first-line drug for anaphylaxis. It treats airway edema, bronchospasm, and vasodilation; antihistamines do not reverse shock or airway obstruction.
NCLEX decision rule Do not make anaphylaxis wait for a complete history, laboratory result, or second-line medication.
References
1World Allergy Organization anaphylaxis guidance
2Emergency management guideline for anaphylaxis
Anaphylaxis with shockThe nurse is at the bedside, emergency medications are available, and the client has a patent IV. Actions that occur nearly simultaneously are combined within a single step.
Anaphylaxis — A rapidly developing systemic hypersensitivity reaction that can compromise airway, breathing, or circulation.
Intramuscular Epinephrine — First-line anaphylaxis treatment injected into the mid-anterolateral thigh for rapid absorption.
Biphasic Reaction — Recurrence of anaphylaxis symptoms after apparent resolution without a new exposure.