A patient who was unable to provide a medication history was admitted to the unit. The patient is receiving penicillin for treatment of an infection. The patient begins to wheeze
Upon assessing the patient, the nurse finds an edematous airway, bronchoconstriction, and a blood pressure of 88/47. The nurse's priority action should be to
a. obtain suction and an oropharyngeal airway device.
b. administer epinephrine (adrenalin).
c. check the oxygen saturation and apply oxygen.
d. administer IV fluids to increase the blood pressure.
ANS: B
The priority is to reverse the allergic reaction. This can be done by administering epinephrine, which is used to treat anaphylaxis (which the patient is manifesting).
Nothing indicates a need for suction.
Checking the oxygen saturation is a waste of time.
IV fluids may be a consideration if the blood pressure does not rise after administration of epinephrine, but epinephrine is the priority.
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