Examkin

Question

Difficulty: MediumPharmacological and Parenteral Therapies

While pushing an intravenous (IV) medication, the nurse observes that the client suddenly develops intense facial flushing and reports a severe, pounding headache along with chest tightness. A rapid assessment reveals a blood pressure of 82/48 mmHg, a heart rate of 118 beats/min with an irregular rhythm, and a respiratory rate of 24 breaths/min. Which of the following is the priority nursing action?

  1. A
    Check the medication record for potential IV fluid incompatibilities.
  2. B
    Administer an ordered PRN dose of intravenous epinephrine.
  3. Stop the medication injection immediately.Answer
  4. D
    Place the client in a left lateral Trendelenburg position.

Answer

The correct priority action is to stop the medication injection immediately.
The client's sudden onset of facial flushing, severe headache, chest tightness, hypotension, and irregular pulse during an IV push administration are the hallmark signs of speed shock. Speed shock is a systemic reaction that occurs when a medication is introduced too rapidly into the circulation, causing the drug concentration to reach toxic levels instantly. The absolute first priority is to stop the injection to prevent any further medication from entering the client's bloodstream.

Step-by-Step Solution

1
Analyze the client's sudden onset of symptoms during the IV push.
The combination of severe facial flushing, pounding headache, chest tightness, hypotension, and irregular pulse directly correlates with the rapid introduction of the medication.
Recognizing the specific clinical presentation differentiates speed shock from other infusion reactions like anaphylaxis or air embolism.
2
Determine the highest priority intervention based on the complication.
The nurse must immediately halt the delivery of the offending agent.
Speed shock occurs when a drug reaches toxic proportions in the blood instantly due to rapid administration. Stopping the injection prevents further toxicity before initiating supportive care.

Key Concept

Parenteral Therapy Safety: Speed Shock Recognition and Management
Rate this question

Topics

Pharmacological and Parenteral Therapies

More questions from this topic