A nurse is caring for a client receiving an intravenous infusion of a cephalosporin antibiotic. The client suddenly reports a feeling of impending doom, throat tightness, and becomes visibly dyspneic with audible wheezing. The client's blood pressure is 85/50 mm Hg, and heart rate is 128 beats/minute. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)
- 1Stop the intravenous cephalosporin infusion.
- 2Ensure a patent airway and apply high-flow oxygen via a non-rebreather mask.
- 3Administer epinephrine intramuscularly into the mid-anterolateral thigh.
- 4Initiate a rapid intravenous bolus of 0.9% sodium chloride.
- 5Administer prescribed intravenous diphenhydramine and methylprednisolone.
Cevap
The correct sequence is: Stop the infusion, ensure airway and apply oxygen, administer intramuscular epinephrine, initiate an intravenous fluid bolus, and finally administer adjunctive medications like diphenhydramine and corticosteroids.
The correct sequence strictly adheres to emergency management protocols for anaphylaxis: eliminate the inciting trigger first, secure Airway and Breathing (oxygen), administer the definitive pharmacological treatment (epinephrine), support Circulation (IV fluids for hypotension), and conclude with adjunctive therapies to prevent recurrence.
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Anahtar Kavram
Prioritization of emergency interventions in anaphylactic shock
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