A client receiving a first dose of IV cefazolin has developed a diffuse rash, hypotension, and shortness of breath. Place the nurse's subsequent actions in the correct order. All options must be used.

Question

Quizplus · Accepted Answer

Anaphylactic shock has an acute onset (20-30 minutes) caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs (eg, antibiotics), foods (eg, shellfish, peanuts), diagnostic agents (eg, contrast), biologic agents (eg, blood, vaccines), and venom (eg, bees, snakes) and results in circulatory failure, laryngeal edema, and severe bronchoconstriction. Management of anaphylactic shock includes: Stop the infusion that is causing the reaction and call for help (eg, rapid response team) (Option E). Ensure patent airway, then administer oxygen via a high-flow nonrebreather mask and prepare for intubation if needed (Option B). Give epinephrine intramuscularly. Epinephrine counteracts the effect of the histamines released, dilating bronchial smooth muscles and providing vasoconstriction. Most deaths from anaphylaxis are due to delaying epinephrine. Maintain blood pressure with normal saline IV fluid (Option C). Administer adjunctive therapies: Bronchodilators (eg, albuterol) to dilate the small airways and reverse bronchoconstriction, antihistamines (eg, diphenhydramine) to modify the hypersensitivity reaction, and corticosteroids (eg, methylprednisolone) to decrease airway inflammation and swelling associated with the allergic reaction (Option A). Continue to reassess vital signs for any changes (Option D). Educational objective: In a client who is experiencing an anaphylactic reaction to an IV medication, it is imperative to first stop the infusion; ensure airway patency and administer oxygen; give epinephrine and initiate IV fluids; and administer adjunctive therapies (antihistamines, bronchodilators, corticosteroids).

A Client Receiving a First Dose of IV Cefazolin Has