A nurse is caring for a client who has developed an allergic reaction to a medication. Which of the following actions should the nurse take first?
A. Administer an antihistamine as prescribed.
B. Stop the medication infusion and disconnect the IV tubing.
C. Assess the client’s respiratory status and oxygen saturation.
D. Notify the provider and document the incident.
E. Notify the provider and document the inciden
The Correct answer and Explanation is:
The correct answer is C. Assess the client’s respiratory status and oxygen saturation.
When a client develops an allergic reaction to a medication, the priority is to ensure the client’s safety, particularly regarding their airway and respiratory status. Allergic reactions can lead to severe symptoms, including anaphylaxis, which may result in airway obstruction or respiratory distress. Therefore, the immediate action is to assess the client’s respiratory status, including observing for signs of difficulty breathing, wheezing, or stridor, and measuring oxygen saturation using a pulse oximeter.
After assessing the respiratory status, the nurse should then take further actions based on their findings. If the respiratory status is compromised, the nurse may need to initiate emergency protocols, which could include administering supplemental oxygen or preparing for advanced airway management.
Following the assessment, stopping the medication infusion and disconnecting the IV tubing (option B) is crucial, as it prevents further exposure to the allergen. However, this action should not come before assessing the client’s condition. Administering an antihistamine (option A) may be necessary but is also secondary to assessing the respiratory status; administering medication without assessing the client can mask symptoms or delay necessary interventions. Notifying the provider and documenting the incident (options D and E) are important steps, but these should follow the immediate assessment and intervention.
In summary, the assessment of the client’s respiratory status is the first critical step in managing an allergic reaction to ensure prompt identification and treatment of any potentially life-threatening complications.