What is the primary nursing concern for a child having an anaphylactic reaction?
a. Identifying the offending allergen
b. Ineffective breathing pattern
c. Increased cardiac output
d. Positioning to facilitate comfort
B
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A Determining the cause of an anaphylactic reaction is important to implement the
appropriate treatment, but the primary concern is the airway.
B Laryngospasms resulting in ineffective breathing patterns is a life-threatening
manifestation of anaphylaxis. The primary action is to assess airway patency,
respiratory rate and effort, level of consciousness, oxygen saturation, and urine
output.
C During anaphylaxis, the cardiac output is decreased.
D During the acute period of anaphylaxis, the nurse's primary concern is the
child's breathing. Positioning for comfort is not a primary concern during a
crisis.
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