A client receiving a first dose of an intravenous antibiotic suddenly reports difficulty swallowing and feeling faint. The nurse observes facial swelling, audible wheezing, and a rapidly dropping blood pressure. Place the following nursing interventions in the correct sequence to manage this acute physiological emergency.
- 1Stop the intravenous antibiotic infusion.
- 2Assess airway patency and administer high-flow oxygen.
- 3Administer intramuscular epinephrine.
- 4Initiate a rapid intravenous infusion of normal saline.
Answer
The correct priority sequence is to first stop the antibiotic infusion, then assess the airway and provide oxygen, followed by administering intramuscular epinephrine, and finally initiating an intravenous normal saline infusion.
In any acute allergic or anaphylactic emergency, the clinical priority framework dictates that the nurse must first remove the offending agent to prevent further physiological deterioration. Following this, the nurse immediately applies the Airway, Breathing, Circulation (ABC) principles. The airway and breathing are stabilized through rapid assessment and supplemental oxygen. Circulation and systemic reversal of the pathophysiological response are then addressed with intramuscular epinephrine, the definitive life-saving treatment. Finally, the accompanying circulatory collapse and distributive shock are managed with rapid intravenous fluid boluses.
Step-by-Step Solution
Key Concept
Prioritization in Anaphylactic Shock Management