The nurse is caring for a client with a history of latex allergies. The client develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this client?

Question

A) Teach the client regarding using a kit that contains treatment for allergic reactions.
B) Administer diphenhydramine (Benadryl) by mouth every 4 hours per the healthcare provider's orders.
C) Administer epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders.
D) Collect a detailed history from the client regarding the history of latex allergies.

Answer 1

Answer: C

For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Diphenhydramine is often given as well but by injection, not by mouth. Intravenous epinephrine using a 1:100,000 concentration may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history, because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.