A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
A) Assess for signs and symptoms of anaphylaxis.
B) Assess for erythema and urticaria.
C) Administer an OTC antihistamine.
D) Administer epinephrine.
Ans: A
Feedback:
If a patient is experiencing an allergic response, the nurse's initial action is to assess the patient for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.
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