A client is receiving a continuous infusion of a new antibiotic. Thirty minutes after the infusion began, the client reports feeling dizzy and lightheaded, and the nurse observes facial flushing and a blood pressure of 88/50 mmHg. What is the nurse's PRIORITY action?
- AStop the antibiotic infusion immediately.
- BIncrease the IV fluid rate to improve blood pressure.
- CAdminister an antihistamine as per standing orders.
- DElevate the client's legs and administer oxygen.
Show answer & explanationAnswer & explanation
Correct answer: A. Stop the antibiotic infusion immediately.
The client is exhibiting signs of an acute allergic reaction, possibly anaphylaxis, to the antibiotic, characterized by dizziness, lightheadedness, facial flushing, and hypotension. The priority action is to stop the offending agent immediately to prevent further exposure and worsening of the reaction. Other interventions would follow.
Why the other options are wrong
- B. Increasing IV fluids might be part of the treatment, but stopping the allergen is the priority to halt the reaction.
- C. Administering an antihistamine might be indicated, but stopping the infusion is the immediate priority to prevent further harm.
- D. Elevating legs and administering oxygen are supportive measures, but the priority is to stop the source of the reaction.
Acute Allergic Reaction (Anaphylaxis)
Anaphylaxis is a severe, life-threatening systemic allergic reaction characterized by sudden onset, rapid progression, and involvement of multiple body systems, often including hypotension, respiratory distress, and skin manifestations. Immediate discontinuation of the causative agent is paramount.
- Rapid onset of symptoms.
- Involves multiple body systems.
- Hypotension is a key sign.
- Stop causative agent immediately.
Memory trick: Stop the trigger, then support the body's fight!