NCLEX-RNPhysiological AdaptationMedium
A client receiving an IV infusion of penicillin suddenly develops hives, audible wheezing, throat tightness, and a blood pressure of 78/44 mmHg. Which action should the nurse take first?
- AStop the infusion immediately and administer intramuscular epinephrine
- BSlow the infusion rate and reassess in 5 minutes
- CPosition the client supine and obtain a full set of vital signs
- DAdminister intravenous diphenhydramine
Show answer & explanationAnswer & explanation
Correct answer: A. Stop the infusion immediately and administer intramuscular epinephrine
This presentation indicates anaphylaxis with airway compromise and hypotension, a life-threatening emergency. The causative agent must be stopped immediately, and epinephrine IM is the first-line, life-saving treatment that must be given without delay.
Why the other options are wrong
- B. Slowing rather than stopping the infusion continues antigen exposure during a severe reaction.
- C. Vital signs and positioning are important but delay definitive life-saving treatment.
- D. Diphenhydramine is an adjunct treatment but does not reverse airway compromise or hypotension quickly enough.
Anaphylaxis Management
A severe, rapid-onset allergic reaction causing airway swelling, bronchospasm, and vasodilation leading to shock; epinephrine IM is first-line treatment.
- Stop the causative agent immediately
- Epinephrine 0.3-0.5 mg IM is first-line treatment
- Antihistamines and steroids are adjuncts, not first-line
Memory trick: Stop it, then shoot it—stop the drug, give epinephrine