Minutes after an IV antibiotic begins, a client develops wheezing, facial swelling, generalized hives, and blood pressure of 74/40 mm Hg. Complete the emergency response.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Wheezing, angioedema, hives, and hypotension minutes after an antibiotic indicate anaphylaxis. Stop the trigger and give IM epinephrine promptly under the emergency protocol, while activating help, supporting airway and oxygenation, giving isotonic fluid as prescribed, and reassessing for repeat epinephrine.
Quick answer Recognize anaphylaxis, stop the antibiotic and give prompt IM epinephrine under the emergency protocol, then support airway, oxygenation, and circulation while reassessing for additional epinephrine.
Why this is correct Rapid wheezing, facial swelling, diffuse hives, and shock after a likely trigger involve multiple organ systems and show life-threatening anaphylaxis. Epinephrine is first-line and should not be delayed for formal diagnostic criteria or antihistamines.
Easy analogy or mental picture The airway is tightening while blood vessels suddenly lose tone and leak fluid; epinephrine counters both processes at once.
Memory hook Airway plus low pressure after a trigger: IM epinephrine first.
NCLEX decision rule Remove the trigger when possible, but never let that delay epinephrine. Activate emergency support, provide high-flow oxygen, prepare airway assistance and isotonic fluid, monitor continuously, and repeat epinephrine according to protocol if symptoms persist.
Why the other choices are wrong Antihistamines do not rapidly reverse shock or airway obstruction. Observation, oral fluids, or waiting for a provider callback delays the first-line lifesaving treatment.
Source
12023 Anaphylaxis Practice Parameter Update
2Resuscitation Council UK Anaphylaxis Guidance
32026 NCLEX-RN Test Plan
The nurse stops the suspected trigger, remains with the client, and activates the emergency response. Epinephrine, oxygen, airway equipment, and isotonic IV fluid are immediately available under the facility's emergency protocol.
Anaphylaxis — A rapid, systemic hypersensitivity reaction that can compromise the airway, breathing, or circulation.
Intramuscular epinephrine — First-line anaphylaxis treatment injected into muscle to rapidly support airway, breathing, and circulation.
Angioedema — Rapid swelling of deeper skin or mucosal tissues that can involve the face, lips, tongue, and airway.