A 35-year-old client presents to the emergency department after being stung by a bee while gardening. The client initially experienced only localized pain and swelling at the sting site on the right forearm. However, over the past 30 minutes, the client has developed facial swelling, particularly around the eyes and lips, throat tightness, difficulty swallowing, shortness of breath, and reports feeling dizzy and lightheaded. Vital signs show: BP 90/60 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. The client appears anxious and states, "I can't breathe properly, and my throat feels like it's closing up." What is the nurse's priority action?
A 35-year-old client presents to the emergency department after being stung by a bee while gardening. The client initially experienced only localized pain and swelling at the sting site on the right forearm. However, over the past 30 minutes, the client has developed facial swelling, particularly around the eyes and lips, throat tightness, difficulty swallowing, shortness of breath, and reports feeling dizzy and lightheaded. Vital signs show: BP 90/60 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. The client appears anxious and states, "I can't breathe properly, and my throat feels like it's closing up."
1Administer oral antihistamines immediately
2Apply ice to the sting site to reduce swelling
3Obtain a detailed allergy history from the client
4Prepare for immediate administration of epinephrine✓ 정답
해설
The client's symptoms and vital signs indicate severe anaphylaxis, requiring immediate epinephrine administration to prevent respiratory and cardiovascular collapse. Other actions are not the priority in this life-threatening situation.
This client is exhibiting classic signs and symptoms of anaphylaxis, a severe, life-threatening systemic hypersensitivity reaction. The progression from localized pain and swelling to facial angioedema, laryngeal edema (throat tightness, difficulty swallowing, sensation of closing), bronchospasm (shortness of breath, wheezing implied by low O2 sat), and cardiovascular compromise (hypotension, tachycardia, dizziness) indicates a rapid escalation involving multiple organ systems. The vital signs—BP 90/60 mmHg (hypotension), HR 110 bpm (compensatory tachycardia), RR 28/min (tachypnea), and O2 sat 88% (severe hypoxemia)—confirm impending respiratory and circulatory collapse. Anaphylaxis demands immediate recognition and intervention, as delays in treatment are directly linked to poor outcomes, including fatality [3,4].
Priority Action and Rationale
The nurse's priority action is to prepare for immediate administration of epinephrine. Epinephrine is the first-line, life-saving medication for anaphylaxis because it directly counteracts the pathophysiological cascade driving the reaction. The clinical presentation here—stridor or throat tightness indicating airway edema, respiratory distress, and distributive shock—represents a true medical emergency where the therapeutic window is critically narrow [3,4]. In anaphylaxis, massive release of mediators such as histamine, leukotrienes, and prostaglandins from mast cells and basophils causes profound vasodilation, increased capillary permeability, and smooth muscle constriction. Epinephrine, through its alpha-1 adrenergic agonist effects, causes immediate vasoconstriction, which reverses hypotension, reduces laryngeal and peripheral angioedema, and decreases capillary leakage. Its beta-2 adrenergic effects provide critical bronchodilation, relieving bronchospasm and improving oxygenation. Additionally, beta-receptor activation suppresses further release of inflammatory mediators, halting the progression of the reaction [3]. The intramuscular route into the anterolateral thigh is the standard for initial management due to rapid and predictable absorption. Given the client's hypotension and respiratory failure, preparing epinephrine is the only action that addresses the immediate threat to airway, breathing, and circulation simultaneously.
Analysis of Incorrect Options
- Option 1 (Administer oral antihistamines immediately): Antihistamines, such as diphenhydramine, are considered second-line or adjunctive therapies in anaphylaxis. They work by blocking histamine receptors, which can help alleviate cutaneous symptoms like urticaria and pruritus, but they do not reverse the life-threatening cardiovascular collapse, laryngeal edema, or bronchospasm. Their onset of action is too slow, and the oral route is contraindicated in a client with throat tightness, difficulty swallowing, and impending airway obstruction due to aspiration risk and delayed absorption. Administering an oral medication is not the priority when the client is demonstrating signs of shock and airway compromise [3,4].
- Option 2 (Apply ice to the sting site to reduce swelling): While a local cold compress might provide symptomatic relief for a localized allergic reaction, it is entirely inappropriate as a priority intervention for systemic anaphylaxis. The venom has already been absorbed systemically, and the life-threatening problems are now occurring in the airway, lungs, and vasculature, far from the sting site. Focusing on the localized site delays the critical, systemic treatment required to save the client's life [4].
- Option 3 (Obtain a detailed allergy history from the client): A thorough history is an important component of comprehensive care to identify triggers and prevent future episodes. However, in the acute phase of anaphylaxis with respiratory distress and hypotension, the client is in no condition to provide a detailed history, and the immediate priority is stabilization of the airway, breathing, and circulation. The history-taking phase must be deferred until after the emergency is managed and the client is stabilized. Prioritizing assessment over a critical intervention violates the nursing process in an emergency context where the need for treatment is immediate and obvious [3].
Clinical Reasoning and Test-Taking Strategy
This question tests the NCLEX-RN priority-setting framework, specifically the "airway, breathing, circulation" (ABC) approach combined with the principle that in an emergency, the intervention that is most critical to prevent imminent death takes precedence. The client's subjective statement, "I can't breathe properly, and my throat feels like it's closing up," directly points to a compromised airway (A) and breathing (B). The vital signs confirm circulatory shock (C). The only option that simultaneously addresses all three components of the lethal triad in anaphylaxis is epinephrine. When a question presents a client in acute distress with a known allergic trigger and rapidly progressing multi-system symptoms, the correct answer is almost invariably the one that involves administering the first-line emergency medication, epinephrine, without delay. The systematic review evidence underscores that prompt recognition and intramuscular epinephrine administration are the cornerstones of anaphylaxis management and the primary factors influencing survival [3,4].
References (research sources)
[3]
Dynamic Branching Virtual Simulation for Management of Medication-Induced Anaphylaxis by Pediatric Nurses: A Pilot Educational Evaluation.Research articleWang S, Wang D. (2026) · DOI: 10.3928/00220124-20260526-01
[4]
Sex-Related Differences in Pediatric Anaphylaxis in a Tertiary Hospital from 2015 to 2022: An Epidemiological Study and Implications for Nursing PracticeResearch articleFernandez-Alonso A, Mateo-Frances V, Noguerales-Fuertes L, Jover-Walsh A, Arana-Arce JS, Cubillo-Heras P, Fernandez-Alonso V. (2026) · DOI: 10.20944/preprints202607.1020.v1
Clinical Practice Guide: Emergency Management of Anaphylaxis
Rapid Recognition
Suspect anaphylaxis when an acute onset of illness involves skin or mucosal tissue changes (e.g., hives, angioedema) and at least one of the following: respiratory compromise (dyspnea, wheeze, stridor) or reduced blood pressure with associated symptoms of end-organ dysfunction (syncope, dizziness). The presence of laryngeal edema with a sensation of throat closure is a critical airway warning.
Immediate Nursing Actions
Activate emergency response: Call for help and ensure a crash cart is at the bedside.
Administer epinephrine first: Prepare and administer intramuscular (IM) epinephrine (1:1000 concentration, 0.3-0.5 mg for adults) into the mid-outer thigh without delay. This is the single most critical intervention.
Position the client: Place the client supine or in a position of comfort. If respiratory distress is predominant, they may prefer sitting upright. Do not have them stand or walk.
Provide high-flow oxygen: Apply 100% oxygen via a non-rebreather mask to target SpO2 >94%.
Secure the airway: Assess for the need for immediate endotracheal intubation due to progressive laryngeal edema. Have equipment for a difficult airway, including a cricothyrotomy kit, readily available.
Ongoing Management and Monitoring
Epinephrine may be repeated every 5-15 minutes if symptoms persist. Establish two large-bore IV lines for aggressive fluid resuscitation with isotonic crystalloid (e.g., 1-2 liters of normal saline) to treat distributive shock. Adjunctive therapies such as H1/H2 antihistamines and corticosteroids are second-line treatments given after epinephrine and stabilization; they do not reverse the immediate life threats. Continuously monitor cardiac rhythm, blood pressure, and oxygen saturation, anticipating the potential need for vasopressor infusions if hypotension is refractory to fluids and IM epinephrine.
Anaphylaxis — A severe, life-threatening systemic hypersensitivity reaction involving multiple organ systems, characterized by airway edema, bronchospasm, and distributive shock.
Epinephrine — The first-line pharmacological agent for anaphylaxis; it causes vasoconstriction, bronchodilation, and reduces mast cell mediator release.
Angioedema — Swelling of the deeper layers of the skin and mucous membranes, often involving the face, lips, and larynx, a hallmark of severe allergic reactions.