A client presents to the emergency department after being stung by a bee. The client reports severe itching, hives, and difficulty breathing. Which nursing intervention should be the priority?
1Apply cold compresses to the sting site to reduce swelling
2Remove the stinger using tweezers to prevent further venom injection
3Administer epinephrine as prescribed for anaphylactic reaction✓ 정답
4Provide oral antihistamines to control allergic symptoms
해설
Priority is administering epinephrine for anaphylaxis, as it addresses life-threatening airway and circulatory issues. Other interventions like cold compresses or antihistamines are supportive but not immediate priorities.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize care for a patient experiencing a severe allergic reaction. The core theme is recognizing and managing anaphylaxis, a life-threatening, systemic hypersensitivity reaction. The pathophysiology involves massive histamine and other mediator release, causing widespread vasodilation, increased capillary permeability, and smooth muscle contraction. This leads to the classic triad of symptoms: respiratory distress (bronchospasm, laryngeal edema), cardiovascular compromise (hypotension, shock), and cutaneous manifestations (itching, hives, angioedema).
Answer Rationale: Key Point! The patient's symptoms of difficulty breathing along with hives and itching indicate a progression beyond a local reaction to a systemic, life-threatening anaphylactic reaction. The priority nursing intervention is to administer epinephrine as prescribed. Epinephrine is the first-line drug because it acts as a potent vasoconstrictor (reversing hypotension and shock), a bronchodilator (relieving bronchospasm), and it stabilizes mast cells to prevent further mediator release. This directly addresses the immediate threats to the patient's airway, breathing, and circulation (ABCs).
Distractor Analysis:
Watch out for confusion! Option ① (Apply cold compresses) is a supportive measure for local swelling and discomfort but does not address the systemic, life-threatening airway and circulatory problems. It is not the priority.
Option ② (Remove the stinger using tweezers) is incorrect technique. The correct method is to scrape it off horizontally with a credit card or fingernail to avoid squeezing more venom into the wound. More importantly, this action, while appropriate, is secondary to stabilizing the patient's airway and breathing.
Option ④ (Provide oral antihistamines) is a supportive treatment for allergic symptoms like itching and hives. However, in anaphylaxis, oral administration is too slow, and antihistamines do not reverse hypotension or bronchospasm. They are adjunctive, not first-line, emergency treatments.
Related Concepts: The nursing process in emergencies follows the ABC (Airway, Breathing, Circulation) priority framework. Anaphylaxis management also includes ensuring a patent airway (may require intubation), administering supplemental oxygen, establishing IV access for fluid resuscitation, and administering adjunctive medications like corticosteroids and antihistamines after epinephrine.
High-Frequency NCLEX Topics
NCLEX frequently tests the priority action in emergency situations. Anaphylaxis is a classic scenario where you must choose the life-saving medication (epinephrine) over other correct but less urgent interventions. Expect questions on recognizing early signs (hoarseness, feeling of throat tightness) and proper administration of epinephrine auto-injectors.
Watch Out for Question Variations!
Shift from Symptom to Intervention: "The nurse notes a client with bee sting has wheezing and swollen lips. What should the nurse do first?" (Answer: Administer epinephrine).
Shift to Patient Education: "A client with a history of anaphylaxis is discharged. Which statement by the client indicates understanding? 'I will carry my epinephrine auto-injector at all times.'"
Shift to Medication Knowledge: "The nurse administers epinephrine for anaphylaxis. Which client assessment is the priority after administration?" (Answer: Monitor respiratory status and breath sounds).
Nursing Clinical Practice GuideClinical Scenario: You are triaging a patient in the ED who was just stung by a bee. They are anxious, scratching their arms, and say, "My throat feels tight, and I can't catch my breath." You observe widespread urticaria (hives) and audible wheezing.
Airway/Breathing: Assess for stridor, hoarseness, use of accessory muscles, oxygen saturation. Call a rapid response/code team.
Priority Intervention:Administer epinephrine 0.3 mg IM in the mid-anterolateral thigh without delay, per protocol or physician order. Do not wait for an order if a standing protocol exists.
Apply high-flow oxygen via non-rebreather mask.
Secondary Interventions (Next 5-10 minutes):
Establish two large-bore IV lines for rapid fluid resuscitation (e.g., 0.9% Normal Saline bolus).
Administer adjunctive medications: IV corticosteroids (e.g., methylprednisolone) and IV antihistamines (e.g., diphenhydramine).
Continuously monitor vital signs, especially blood pressure, heart rate, and oxygen saturation.
Assist with advanced airway management (e.g., intubation) if needed.
Ongoing Care & Education:
Monitor for a biphasic reaction (symptoms returning hours later).
Educate the patient on allergen avoidance, recognition of early symptoms, and proper use of an epinephrine auto-injector (EpiPen).
Arrange follow-up with an allergist.
Patient Safety and Precautions:
Epinephrine Administration: Use the IM route for rapid absorption. Avoid subcutaneous injection as absorption is slower. Do not inject into buttocks or digits.
Stinger Removal: If visible, scrape it off; do not use tweezers to pinch it, as this can inject more venom.
Positioning: Place the patient in a supine position with legs elevated if hypotensive to promote venous return. If breathing is severely compromised, a semi-Fowler's position may be more comfortable, but be prepared to lay the patient flat if hypotension worsens.
Nursing Procedure & Medication FlowEpinephrine (1:1,000) IM Administration for Anaphylaxis:
Draw up 0.3 mg (0.3 mL) of 1:1,000 epinephrine for an adult.
Select site: Mid-anterolateral thigh.
Clean site with alcohol swab.
Inject at a 90-degree angle into the muscle.
Massage the area gently after injection to enhance absorption.
Document: Time, dose, route, site, patient's response, and any adverse effects.
Key Monitoring Post-Epinephrine: Heart rate, blood pressure, ECG for dysrhythmias, respiratory rate, breath sounds, and resolution of symptoms. Be prepared to repeat the dose in 5-15 minutes if symptoms persist.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In a situation like anaphylaxis, seconds count. Your rapid assessment and decisive action to give epinephrine can be the difference between life and death. In clinical practice, trust your ABCs. If a patient says their throat is closing, believe them and act immediately. When studying for your boards, don't just memorize 'epinephrine for anaphylaxis' — understand why it works (vasoconstriction, bronchodilation) and why it comes before antihistamines (speed and mechanism of action). That deep understanding will make you a confident, life-saving nurse."
Anaphylaxis — A severe, life-threatening systemic allergic reaction characterized by respiratory distress, hypotension, and cutaneous symptoms.
Epinephrine — First-line medication for anaphylaxis; acts as an alpha and beta adrenergic agonist to cause vasoconstriction, bronchodilation, and increased cardiac output.
ABC Priority (Airway, Breathing, Circulation) — The fundamental framework for prioritizing care in any emergency situation, ensuring life-threatening issues are addressed first.
Urticaria — Raised, itchy welts on the skin, a common manifestation of an allergic reaction.
Bronchospasm — Constriction of the smooth muscle in the bronchi, leading to wheezing and difficulty breathing; a key feature of anaphylaxis.