A nurse is caring for a client with a severe sunburn on the back and shoulders. The client reports pain, redness, and blistering. Which nursing action should the nurse implement first?
A 35-year-old client presents to the emergency department after being stung by a bee while gardening. The client reports immediate sharp pain at the sting site on the left forearm, followed by localized swelling and redness.
1Apply a warm compress to the sting site to promote circulation
2Remove the stinger by scraping it out with a credit card or fingernail✓ 정답
3Administer oral antihistamine medication as prescribed
4Apply topical corticosteroid cream to reduce inflammation
해설
Priority is removing the stinger by scraping to prevent continued venom injection. Other actions like warm compresses or antihistamines are secondary after stinger removal.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a bee sting. The core principle is preventing further harm by stopping the ongoing envenomation. A bee's stinger is barbed and remains embedded in the skin, with an attached venom sac that can continue to inject venom for several seconds to minutes after the sting.
Answer Rationale: Key Point! The first and most critical action is to remove the stinger promptly to minimize the total venom dose. The correct technique is to scrape it off horizontally (e.g., with a credit card, fingernail, or knife blade) rather than using tweezers or pinching it, as squeezing the venom sac can inject more venom into the wound.
Distractor Analysis:
Watch out for confusion! Applying a warm compress (Option 1) is generally contraindicated in the initial management of a bee sting. Heat can increase vasodilation and potentially speed the systemic absorption of venom. Cool compresses are typically used to reduce pain and swelling.
Administering oral antihistamines (Option 3) or applying topical corticosteroids (Option 4) are appropriate interventions to manage the local inflammatory response (itching, redness, swelling) after the stinger has been removed. However, they are not the immediate priority. Furthermore, in an emergency setting, the nurse would first assess for signs of a systemic allergic reaction (anaphylaxis) before administering any medication.
Related Concepts: This scenario highlights the nursing process step of Implementation, specifically prioritizing actions based on patient safety and the pathophysiology of the injury. The nurse must also be vigilant for signs of anaphylaxis (e.g., dyspnea, wheezing, throat tightness, hypotension, generalized urticaria), which would become the absolute priority and require immediate administration of epinephrine.
Concept Summary
Concept
Key Takeaway
Bee Stinger Removal
Priority action. Scrape, don't squeeze, to prevent further venom injection.
Local Reaction Management
Cool compresses, oral antihistamines, topical corticosteroids are secondary interventions.
Anaphylaxis Vigilance
Assess for systemic signs (ABCs - Airway, Breathing, Circulation) as the highest priority if present.
Nursing Process: Prioritization
First, stop the ongoing threat (remove stinger), then manage symptoms and prevent complications.
Reduces pain, vasoconstricts to limit swelling. (Avoid heat).
Administer oral antihistamine
After stinger removal, for itching/hives
Manages histamine-mediated symptoms. Not for anaphylaxis.
Apply topical corticosteroid
After stinger removal, for significant local inflammation
Reduces inflammation. Slower onset than cool compress.
Administer Epinephrine (IM)
Absolute Priority if anaphylaxis signs present
First-line drug for anaphylaxis (bronchospasm, hypotension).
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Bee venom contains proteins (e.g., melittin, phospholipase A2) that trigger mast cell degranulation, releasing histamine and other inflammatory mediators. This causes local pain, redness, swelling (wheal and flare), and itching.
Anaphylaxis Mechanism: In sensitized individuals, IgE-mediated massive systemic release of mediators causes widespread vasodilation (hypotension), bronchoconstriction (wheezing), and increased vascular permeability (edema, especially dangerous in the larynx).
Pharmacology:Epinephrine is an alpha- and beta-adrenergic agonist. Alpha effects reverse vasodilation and edema, while beta effects dilate bronchi and increase heart rate, countering the life-threatening symptoms of anaphylaxis.
Memory Tips
ABCs & Stinger: For bee stings, think "Remove the Stinger First," but always be ready for "ABCs (Airway, Breathing, Circulation) First" if anaphylaxis is suspected. The stinger is the ongoing problem; anaphylaxis is the immediate life threat.
Scrape, Don't Squeeze: Remember this rhyme. Pinching with tweezers injects more venom.
Cool, Not Hot: Heat is wrong for fresh stings/bites. Cool compresses are correct.
High-Frequency NCLEX Topics
This integrates several high-yield NCLEX areas: prioritization (first action), first aid/emergency care, allergic reactions, and patient education (how to properly remove a stinger). NCLEX loves to test the subtle difference between a local reaction (manage symptoms) and anaphylaxis (treat as a medical emergency).
Watch Out for Question Variations!
Shift to Anaphylaxis: The question could add: "The client develops wheezing and facial edema. Which action should the nurse take first?" Answer: Administer epinephrine IM and call a rapid response/code.
Shift to Patient Education: "The nurse is teaching a parent about home care for a child's bee sting. Which instruction is most important?" Answer: "Scrape the stinger off with a credit card or fingernail."
Shift to Medication Knowledge: "The client with a known bee allergy is prescribed an epinephrine auto-injector. The nurse should teach the client to administer it into which site?" Answer: The anterolateral aspect of the thigh.
Nursing Clinical Practice GuideClinical Scenario: You are triaging a patient in the Emergency Department (ED) who was stung on the forearm 10 minutes ago. The patient is alert but anxious, pointing to a red, swollen area with a visible black stinger in the center.
Nursing Intervention Strategy:
Immediate Assessment & Action (First 60 seconds):
Primary Survey (ABCs): Quickly assess airway patency, breathing (listen for stridor/wheezing), and circulation (check radial pulse, skin color). Ask: "Is your throat feeling tight? Are you having trouble breathing?" This rules out immediate anaphylaxis.
Remove the Stinger: If no anaphylaxis signs, put on gloves. Use the edge of a patient ID band or a gauze pad to firmly scrape across the skin's surface to dislodge the stinger. Inspect to ensure it is completely removed.
Secondary Assessment & Care (Next 5-10 minutes):
Cleanse the area with soap and water or an antiseptic wipe.
Apply a cool compress or ice pack (wrapped in a towel) to the site for 15-20 minutes to reduce pain and swelling.
Assess pain level and medicate as per protocol/order (e.g., oral analgesics like acetaminophen or ibuprofen).
If itching is prominent, an oral antihistamine (e.g., diphenhydramine or cetirizine) may be administered as ordered.
For significant local swelling, a topical corticosteroid cream may be applied.
Monitoring & Education:
Monitor the site and the patient for at least 30-60 minutes for any delayed allergic response.
Educate the patient on signs of delayed reaction or infection (increasing redness, warmth, pus, fever) and instruct them to seek care if these occur.
If the patient has a known severe allergy, reinforce the use of their epinephrine auto-injector and the importance of seeking emergency care after use.
Patient Safety and Precautions:
Never use tweezers to pinch and pull a bee stinger, as this compresses the venom sac.
Contraindication: Do not apply heat. It increases blood flow and can worsen swelling and pain.
Anaphylaxis is the priority: If the patient shows ANY signs of systemic involvement (hives beyond the sting site, swelling of lips/tongue, hoarseness, dyspnea, dizziness, nausea), activate the emergency response system, administer epinephrine IM immediately, and prepare for advanced airway management.
Nursing Procedure & Medication FlowStinger Removal Procedure: 1. Don gloves. 2. Identify stinger (looks like a small black splinter). 3. Place a rigid, flat edge (card, knife blade) against the skin at the base of the stinger. 4. Apply firm, sweeping pressure to scrape the stinger out. 5. Dispose of stinger. 6. Cleanse wound.
Epinephrine Administration (for Anaphylaxis):
Drug: Epinephrine 1:1,000 solution.
Route & Dose: Intramuscular (IM) injection in the anterolateral thigh. Adult dose typically 0.3-0.5 mg.
Key Monitoring: After administration, continuously monitor vital signs, oxygen saturation, and respiratory effort. Be prepared for repeat doses every 5-15 minutes if symptoms persist.
A Word from Your Senior Nurse
"In the rush of an emergency, it's easy to jump to what seems most obvious—like putting something on the wound. But nursing is about thinking one step ahead: what is causing the problem right now? With a bee sting, the problem isn't just the pain or swelling; it's the little venom pump still attached to your patient. Removing it is a simple, 5-second action that can make a huge difference in their recovery. Always ask yourself: 'Am I treating the symptom, or am I stopping the cause?' That critical thinking is what makes you a great nurse, both on the NCLEX and at the bedside."
Bee Stinger — The barbed, venom-injecting apparatus left behind by a honeybee after a sting. It must be removed by scraping to prevent continued envenomation.
Anaphylaxis — A severe, life-threatening systemic allergic reaction characterized by bronchospasm, laryngeal edema, hypotension, and urticaria. Requires immediate epinephrine.
Epinephrine — First-line medication for anaphylaxis. It acts as an alpha- and beta-adrenergic agonist to reverse bronchoconstriction and hypotension.
Local Inflammatory Reaction — The expected response to a bee sting: pain, redness (erythema), swelling (edema), and itching at the site, mediated by histamine and other chemicals.
Scraping Technique — The recommended method for bee stinger removal using a flat, rigid object (e.g., credit card) to horizontally scrape the stinger out, avoiding compression of the venom sac.