Management of Care Q 14
After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?
A. Page an anesthesiologist immediately and prepare to intubate the client.
B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.
D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
Correct Answer: B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed.
Option A: The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don’t relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client.
Option C: No antidote for penicillin exists; however, the nurse should continue to monitor the client’s vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.
Option D: An indwelling catheter is not needed in a client experiencing anaphylactic shock; however, IV fluids may be ordered by the physician after.