A nurse administered glatiramer (Copaxone) just 10 minutes ago. The patient calls the nurses' station to report itching. Upon assessment the nurse notes that the patient is flushed and has pal-pitations, anxiety, and chest pain
What action should the nurse take first? a. Explain to the patient that the symptoms occur with some patients and will pass within 15 to 20 minutes.
b. Prepare to administer epinephrine, because the patient is experiencing the onset of anaphylaxis.
c. Prepare the crash cart.
d. Elevate the head of the bed, apply oxygen, and maintain the airway.
A
About 10% of patients who receive glatiramer experience self-limited, postinjection reactions, characterized by flushing, palpitations, severe chest pain, anxiety, laryngeal constriction, and ur-ticaria. The reaction typically does not last longer than 15 to 20 minutes, but the patient should be monitored.
The symptoms described are expected and do not indicate anaphylaxis, therefore epinephrine should not be administered.
The symptoms do not indicate an emergency situation, therefore the crash cart is not needed.
The symptoms do not indicate anaphylaxis, therefore no treatment is required at this time.
NCLEX Client Needs Category:
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