. A school nurse is caring for a child who is having an allergic response. What should be the initial action of the school nurse?
A) Assess for signs/symptoms of anaphylaxis
B) Assess for erythema and urticaria
C) Assess for cause of allergic reaction
D) Assess vital signs
Ans: A
Feedback: If a patient is experiencing an allergic response, the nurse's initial action is to assess the patient for signs and symptoms of anaphylaxis. The nurse assesses the airway, breathing pattern, and vital signs. All options are valid assessments, but they are not the initial action of the nurse.
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