A client receiving an initial intravenous dose of ceftriaxone suddenly reports tightness in the throat and severe shortness of breath. The nurse observes facial angioedema and notes a precipitous drop in blood pressure to 82/48 mm Hg. Place the following emergency nursing actions in the correct order of priority, from first to last.
- 1Stop the intravenous antibiotic infusion immediately.
- 2Assess airway patency and administer high-flow oxygen.
- 3Administer intramuscular epinephrine into the anterolateral thigh.
- 4Elevate the client's lower extremities.
- 5Administer prescribed intravenous diphenhydramine and corticosteroids.
Answer
The correct priority sequence is to stop the antibiotic infusion, assess the airway and provide oxygen, administer intramuscular epinephrine, elevate the lower extremities, and finally administer adjunctive medications.
In acute anaphylaxis, the priority framework relies on removing the inciting agent followed by ABCs (Airway, Breathing, Circulation). Stopping the infusion prevents further antigen load. Securing the airway and applying oxygen addresses the most immediate threat to life (hypoxia). Intramuscular epinephrine is the priority pharmacological intervention to reverse shock and bronchospasm. Elevating the legs supports circulation (blood pressure), and administering secondary drugs like diphenhydramine resolves lingering symptoms and prevents recurrence.
Step-by-Step Solution
Key Concept
Management of acute anaphylaxis and physiological decompensation requires immediate removal of the trigger followed by adherence to the ABC (Airway, Breathing, Circulation) prioritization framework.
Estimated Time:1m 30s