An hour after taking a medication, a nurse notes that the patient displays urticaria and pruritus. The nurse's priority action for this patient would be to
a. leave the patient to call the prescriber.
b. assess for changes in respiratory pattern and wheezing.
c. document the findings.
d. administer epinephrine to the patient STAT.
B
Patients who develop urticaria (hives) and pruritus are at risk for anaphylaxis, which would be indicated by bronchoconstriction and wheezing. Note: As a test strategy, when answering a priority question, make sure you go through the ABCs, then other physiological priorities, then safety and security priorities, then love and belonging priorities. This is clearly an ABC priority.
Never leave the patient, because the allergic reaction may precipitate anaphylaxis, and you would need to assess for changes in respiratory status.
Simply documenting the findings ignores the patient risk for anaphylaxis.
Epinephrine should be administered only in the event of anaphylaxis.
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