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Difficulty: MediumPharmacological and Parenteral Therapies

A nurse is caring for a client who is receiving an initial intravenous dose of ceftriaxone for a severe respiratory infection. Ten minutes after the infusion begins, the client develops sudden wheezing, facial swelling, and reports a feeling of impending doom. Which of the following nursing actions are appropriate? (Select all that apply.)

  1. Stop the ceftriaxone infusion immediately.Answer
  2. Attach new intravenous tubing primed with 0.9% sodium chloride to the catheter hub.Answer
  3. Prepare to administer intramuscular epinephrine.Answer
  4. D
    Delegate the immediate collection of vital signs to the unlicensed assistive personnel (UAP).
  5. E
    Administer the prescribed intravenous diphenhydramine before stopping the antibiotic infusion.
  6. F
    Inform the client that facial swelling is an expected side effect of the medication.

Answer

The correct actions are to stop the ceftriaxone infusion immediately, attach new intravenous tubing primed with 0.9% sodium chloride, and prepare to administer intramuscular epinephrine.
Anaphylaxis is a severe, life-threatening hypersensitivity reaction. The absolute first priority is to stop the offending medication. Following this, the nurse must maintain intravenous access using new tubing (to avoid pushing remaining antibiotic into the client) and prepare to administer epinephrine, which is the first-line medication for reversing anaphylactic shock.

Step-by-Step Solution

1
Analyze the client's sudden onset of symptoms (wheezing, facial swelling, impending doom).
Identify these manifestations as classic signs of a severe, life-threatening anaphylactic reaction.
Early recognition of anaphylactic shock dictates the speed and direction of emergency nursing interventions.
2
Determine the first priority action regarding the intravenous therapy.
Stop the ceftriaxone infusion immediately.
Stopping the infusion prevents further exposure to the allergen triggering the anaphylactic cascade.
3
Determine how to safely maintain intravenous access.
Change the IV tubing and attach new tubing primed with normal saline at the catheter hub.
Intravenous access is vital for emergency drugs, but flushing the existing tubing would push the remaining antibiotic allergen into the client's circulation.
4
Identify the primary pharmacological intervention for anaphylaxis.
Prepare to administer intramuscular epinephrine.
Epinephrine is the first-line medication required to reverse the life-threatening bronchoconstriction and vasodilation of anaphylaxis.

Key Concept

Management of Anaphylactic Shock During Parenteral Therapy
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Topics

Pharmacological and Parenteral Therapies

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