The nurse working in an immunization clinic administers a vaccine to the client. While the nurse is documenting the vaccine, the client says, "All of a sudden, I feel like my lips are tingling." What is the nurse's priority of care?
1. Monitor vital signs.
2. Assess the client's airway.
3. Provide client teaching.
4. Administer diphenhydramine by standing order.
2
Rationale: The greatest priority of care for this client is assessing and maintaining an open airway. Tingling of the lips could be an early indication of an anaphylactic reaction, which can cause tracheobronchial edema. The physician should be notified and the vital signs monitored. Diphenhydramine may be administered, but it will not be sufficient to reverse anaphylaxis if it is occurring.
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