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NCLEX · Emergency Response

A client is experiencing an anaphylactic reaction. What is the priority intervention?

Reviewed by Jordan Morley, Editorial Lead at 247SimpleTests. Written by the 247SimpleTests Editorial Team from the official source material cited on every question.

Correct answer

Stop the precipitating agent (if applicable), maintain the airway, administer epinephrine intramuscularly per protocol, call for help, prepare for possible intubation

  1. A Stop the precipitating agent (if applicable), maintain the airway, administer epinephrine intramuscularly per protocol, call for help, prepare for possible intubation
  2. B Give oral antihistamines
  3. C Document the reaction
  4. D Place the client in a chair

Why this is the answer

Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate action. Signs: hives, urticaria, swelling (face, lips, tongue, throat), wheezing, stridor, hypotension, shock. Priority interventions: (1) Stop the offending agent — discontinue IV infusion, remove contact; (2) Assess and maintain the airway — anaphylaxis can cause rapid airway swelling; (3) Administer epinephrine IM (epinephrine auto-injector or 1:1000 solution, 0.3-0.5 mg adult dose, IM in vastus lateralis) — epinephrine is the first-line treatment, given immediately; (4) Call rapid response or code team; (5) Position supine with legs elevated unless respiratory distress requires sitting up; (6) Administer high-flow oxygen; (7) Establish IV access for fluids and additional medications; (8) Prepare for possible intubation. Secondary medications: antihistamines (diphenhydramine), corticosteroids (methylprednisolone), bronchodilators if wheezing. Epinephrine works within minutes; a second dose may be needed in 5-15 minutes.
Source: NCLEX-RN Test Plan, Emergency Response — Anaphylaxis

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About this topic: Emergency Response

Emergency response questions cover triage, disaster planning, code situations, rapid response criteria and the nurse's role during a fire, evacuation or mass-casualty event. This is one of 6 RN: Safe and Effective Care Environment questions on emergency response, each with a full explanation on a single study page.

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