# A 55-year-old client who started enalapril 5 mg orally twice daily 3 days ago presents to the emergency department with swollen lips and tongue, hoarse voice, and mild stridor. Vital signs: BP 138/82, HR 102, RR 24, SpO2 95% on room air. Which set of actions reflects the priority sequence?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374903&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 55-year-old client who started enalapril 5 mg orally twice daily 3 days ago presents to the emergency department with swollen lips and tongue, hoarse voice, and mild stridor. Vital signs: BP 138/82, HR 102, RR 24, SpO2 95% on room air. Which set of actions reflects the priority sequence?

## Option

1. Hold the enalapril, prepare for emergent airway management with intubation supplies at bedside, and administer IM epinephrine per provider order or standing protocol. **✔ Correct answer**
2. Apply a cold compress to the lips and tongue, administer acetaminophen 650 mg for discomfort, and reassess the client after 1 hour for improvement.
3. Administer the next scheduled dose of enalapril as prescribed, position the client in high-Fowler's, and obtain a stat complete blood count and basic metabolic panel.
4. Administer oral diphenhydramine 50 mg, monitor oxygen saturation every 30 minutes, and prepare for discharge with a prescription for an antihistamine if symptoms subside.

**Correct answer: 1**

## Explanation

ACE inhibitor angioedema — airway emergency
ACE inhibitor angioedema is a life-threatening, non-allergic, bradykinin-mediated reaction that can occur from hours to years after initiation. Hallmarks: lips·tongue·face·glottis swelling, hoarseness, stridor, and rapid airway compromise. Antihistamines and corticosteroids are not effective (this is bradykinin-, not histamine-, mediated), but IM epinephrine, fresh frozen plasma, icatibant (bradykinin B2 antagonist), and C1-esterase inhibitor have been used per protocol. The first nursing actions are: hold the offending drug forever (lifelong contraindication, including ARB cross-reactivity in some patients), prepare for emergent intubation/cricothyrotomy, position upright, and administer IM epinephrine if standing protocol or order. The condition can deteriorate within minutes — never delegate observation only or rely on oral antihistamine.

## In-depth explanation

Clinical reasoning summary
ACE inhibitor angioedema — airway emergency
ACE inhibitor angioedema is a life-threatening, non-allergic, bradykinin-mediated reaction that can occur from hours to years after initiation. Hallmarks: lips·tongue·face·glottis swelling, hoarseness, stridor, and rapid airway compromise. Antihistamines and corticosteroids are not effective (this is bradykinin-, not histamine-, mediated), but IM epinephrine, fresh frozen plasma, icatibant (bradykinin B2 antagonist), and C1-esterase inhibitor have been used per protocol. The first nursing actions are: hold the offending drug forever (lifelong contraindication, including ARB cross-reactivity in some patients), prepare for emergent intubation/cricothyrotomy, position upright, and administer IM epinephrine if standing protocol or order. The condition can deteriorate within minutes — never delegate observation only or rely on oral antihistamine.

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