A child has experienced a "bee-sting" while at the park. The health care provider is walking by and notices the child has swelling around the eyes, lips, and face in general. What priority assessment should the nurse make at this time?
A) Palpate for carotid pulses in the neck.
B) Assess skin on the truck and back for development of hives.
C) Assess and establish an open airway.
D) Try to listen to breath sounds by placing your ear on the child's chest.
Ans: C
Feedback:
The initial management of anaphylaxis focuses on the establishment of a stable airway and intravenous access and the administration of epinephrine. Epinephrine produces relaxation of bronchial smooth muscle and inhibits the immediate life-threatening cardiovascular effects of anaphylaxis. All the other assessments (pulse rate, skin, and breath sounds) can be done after the airway is assessed and managed.
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