The nurse is caring for a client who just had an intravenous pyelogram (IVP). The client suddenly develops severe urticaria, angioedema, dyspnea, and cyanosis. Which of these actions should the nurse take first?
a. Administer epinephrine subcutaneously.
b. Maintain the airway and administer oxygen via mask.
c. Notify the health care provider for medication orders.
d. Start an IV line of D5W.
A
Anaphylaxis is a potentially life-threatening type I systemic reaction to allergens. Clients who are extremely sensitive to a particular allergen (e.g., shellfish, chocolate, antibiotics) suddenly develop symptoms such as flushing, nasal and throat congestion, and severe dyspnea, which can lead to respiratory failure, severe hypotension, and death. Medical management of clients who have anaphylactic reactions involves life-supporting treatment measures. Administering epinephrine subcutaneously will decrease the client's response and open the airway.
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