A nurse is administering a newly prescribed intravenous antibiotic. Ten minutes into the infusion, the client reports severe shortness of breath, a tight feeling in the throat, and dizziness. The client's blood pressure is mm Hg and heart rate is bpm. Arrange the following nursing interventions in the correct order of priority.
- 1Stop the intravenous antibiotic infusion immediately.
- 2Maintain a patent airway and administer high-flow oxygen.
- 3Administer intramuscular epinephrine into the vastus lateralis.
- 4Elevate the lower extremities and initiate a rapid intravenous fluid bolus.
- 5Administer adjunctive intravenous diphenhydramine and corticosteroids.
Answer
The correct sequence is to stop the triggering agent, secure the airway and provide oxygen, administer the first-line medication (epinephrine), support circulation with positioning and fluids, and finally administer adjunctive medications.
In any medical emergency involving a continuous intravenous triggering agent, the first and most critical action is to stop the infusion. Following this, the nurse must adhere to the ABC (Airway, Breathing, Circulation) framework. Ensuring a patent airway and providing oxygen addresses the most immediate threat to life (laryngeal edema and hypoxia). Once the airway is supported, intramuscular epinephrine is the absolute priority pharmacological intervention, as it directly reverses bronchospasm and severe vasodilation. After epinephrine administration, circulatory support is provided through leg elevation and rapid isotonic fluid boluses to treat distributive shock. Finally, adjunctive medications such as antihistamines and corticosteroids are administered to alleviate ongoing symptoms and prevent biphasic allergic reactions.
Step-by-Step Solution
Key Concept
Prioritization of clinical interventions in acute anaphylactic shock utilizing the ABC framework.