A patient is demonstrating hypovolemic shock as a result of anaphylaxis from an insect sting. Which of the following should the nurse implement first for this patient?
1. epinephrine 1:1000 0.5 mg sq
2. normal saline at 150 cc/hr
3. Benadryl/diphenhydramine 50 mg intravenously
4. oxygen at 3 liters via nasal cannula
1
Rationale: The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. Although the other orders are appropriate, they must be done after an airway has been established.
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