A nurse is caring for a client who is receiving an intravenous infusion of ceftriaxone for a severe infection. Ten minutes into the infusion, the client suddenly reports throat tightness, severe dizziness, and develops visible facial swelling. Arrange the following nursing actions in the correct order of priority.
- 1Stop the intravenous antibiotic infusion.
- 2Assess airway patency and apply high-flow oxygen.
- 3Administer intramuscular epinephrine.
- 4Initiate a rapid bolus of 0.9% sodium chloride.
- 5Administer intravenous diphenhydramine.
Answer
Stop the infusion, assess the airway and apply oxygen, administer intramuscular epinephrine, initiate an IV fluid bolus, and finally administer intravenous diphenhydramine.
The correct sequence relies on the core principles of emergency management: removing the offending agent, stabilizing the ABCs (Airway, Breathing, Circulation), and administering therapies in order of life-saving necessity. Stopping the antibiotic halts further antigen exposure. Immediately assessing the airway and oxygenating the client addresses the highest immediate risk (asphyxiation). Epinephrine is the definitive primary treatment for anaphylaxis to reverse respiratory and hemodynamic compromise. IV fluids then support circulation to correct distributive shock. Finally, adjunctive medications like diphenhydramine are given to manage non-life-threatening symptoms.
Step-by-Step Solution
Key Concept
Prioritization of emergency interventions during acute anaphylactic shock.