NCLEX · Reduction of Risk Potential

After administering an IV antibiotic, the client develops difficulty breathing, urticaria, and hypotension. What is the priority action?

Correct answer

Stop the infusion immediately, maintain airway, call for help, administer epinephrine per protocol, prepare for advanced airway management

  1. A Slow the infusion rate
  2. B Stop the infusion immediately, maintain airway, call for help, administer epinephrine per protocol, prepare for advanced airway management
  3. C Document the reaction and continue
  4. D Administer another dose

Why this is the answer

This is anaphylactic reaction to the IV antibiotic. Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate action: (1) Stop the offending agent immediately — close the IV clamp; (2) Maintain the airway — anaphylaxis can cause rapid laryngeal swelling; (3) Call for help (rapid response or code team); (4) Administer epinephrine IM (0.3-0.5 mg adult dose, 1:1000 solution, IM in vastus lateralis) — epinephrine is first-line and given immediately; (5) Position supine with legs elevated unless respiratory distress requires head elevated; (6) Apply high-flow oxygen; (7) Establish second IV; bolus fluids for hypotension; (8) Continuous monitoring; (9) Prepare for intubation. Secondary medications: diphenhydramine (antihistamine), methylprednisolone (corticosteroid), bronchodilator if wheezing. After stabilization: identify the allergen, document the reaction, update the medical record allergy list, place an allergy band, educate the client and family. Biphasic reactions can occur 8-12 hours later, so observation period is required.
Source: NCLEX-RN, Reduction of Risk — Anaphylaxis