NCLEX-PN® ExaminationPhysiological AdaptationHard
A client is experiencing a severe allergic reaction after receiving a new medication. The nurse notes widespread urticaria, angioedema, wheezing, and a blood pressure of 80/40 mmHg. Which medication is the priority for the nurse to administer?
- AEpinephrine
- BAlbuterol
- CDiphenhydramine
- DMethylprednisolone
Show answer & explanationAnswer & explanation
Correct answer: A. Epinephrine
The client's symptoms (widespread urticaria, angioedema, wheezing, and hypotension) are indicative of anaphylaxis, a severe, life-threatening allergic reaction. Epinephrine is the first-line and most critical medication for anaphylaxis because of its alpha-adrenergic effects (vasoconstriction, increasing blood pressure) and beta-adrenergic effects (bronchodilation, decreasing airway swelling). Immediate administration is vital to prevent circulatory collapse and respiratory failure.
Why the other options are wrong
- B. Albuterol (a bronchodilator) helps with wheezing but does not address the hypotension or systemic effects of anaphylaxis as comprehensively as epinephrine.
- C. Diphenhydramine (an antihistamine) helps with skin symptoms but does not address the life-threatening respiratory or cardiovascular collapse.
- D. Methylprednisolone (a corticosteroid) helps prevent late-phase reactions but is not an immediate life-saving drug for acute anaphylaxis.
Anaphylaxis Management
A severe, systemic allergic reaction that is rapid in onset and may cause death. It involves multiple body systems and requires immediate intervention.
- Triggers include drugs, food, insect stings, latex.
- Symptoms: widespread urticaria, angioedema, wheezing, dyspnea, hypotension, GI symptoms.
- Epinephrine is the first-line treatment, administered intramuscularly.
Memory trick: Anaphylaxis: Epi First, Save Lives Fast!