A patient arrives in the emergency department after developing a rash, runny nose, and sneezing after eating strawberries. What action will the nurse expect to take first?
a. Administer diphenhydramine.
b. Administer epinephrine.
c. Assess for urinary retention.
d. Assess heart rate, respiratory rate, and lung sounds.
ANS: D
The patient probably has a food allergy, since eating strawberries is the precipitating event. The nurse should assess cardiac and respiratory status to determine whether the patient is developing an anaphylactic reaction. Diphenhydramine will be given for mild allergic symptoms of rash, runny nose, and sneezing, but epinephrine must be given for anaphylaxis. Urinary retention is a side effect of diphenhydramine and will be assessed if diphenhydramine is given.
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