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 and assess the severity of the reaction. Allergic reactions can lead to various symptoms, some of which may compromise respiratory function, such as difficulty breathing, wheezing, or anaphylaxis, which is a severe, potentially life-threatening reaction.
Assessing the client’s respiratory status involves checking for signs of respiratory distress, such as increased respiratory rate, use of accessory muscles, and changes in oxygen saturation levels. By measuring oxygen saturation, the nurse can determine if the client is receiving adequate oxygen and whether there is a need for immediate interventions like supplemental oxygen or emergency medications. This assessment is crucial before any further actions, including stopping medications or administering antihistamines.
Once the assessment is completed, the nurse can proceed with the necessary actions based on the findings. If respiratory distress is present, stopping the medication infusion (option B) is essential to prevent further exposure, and notifying the provider (options D and E) is also critical for further management and documentation. Administering an antihistamine (option A) may be appropriate for mild reactions but is not the priority if the client shows signs of respiratory compromise.
In summary, the initial step in managing an allergic reaction is to assess the client’s respiratory status and oxygen saturation to identify the severity of the reaction. This prioritization aligns with the nursing process and ensures that interventions are based on the client’s immediate needs, focusing on maintaining airway and breathing before addressing medication administration or documentation.