A nurse is caring for a client who is experiencing a hypersensitivity.

A client is started on an IV antibiotic to treat a severe infection.

During infusion, the client uses the call light to notify the nurse that she feels a tight sensation in her throat and it is making it hard to breathe.

The nurse immediately arrives to the room and assesses the client.

While auscultating the lungs the nurse notes wheezing.

The nurse also notices that the client is starting to scratch her face and arms, and on closer inspection of the face she also notices redness and swelling.

The nurse suspects anaphylactic shock.

Select all the appropriate interventions for this client:

Choice A rationale

Initiating cardiopulmonary resuscitation (CPR) is typically reserved for cardiac arrest or complete respiratory arrest. In this scenario, the client is experiencing respiratory distress, but there is no indication of complete cessation of cardiac or respiratory function that would warrant immediate CPR. Focusing on addressing the anaphylactic reaction directly is the priority to prevent progression to cardiac arrest.

Choice B rationale

Placing the patient on oxygen is crucial because anaphylaxis often involves bronchoconstriction and laryngeal edema, leading to impaired gas exchange and hypoxemia. Supplemental oxygen increases the partial pressure of inspired oxygen, thereby improving arterial oxygen saturation and mitigating the cellular hypoxia that can result from compromised airway and breathing. Normal oxygen saturation is 95-100%.

Choice C rationale

Slowing down the antibiotic infusion is an insufficient intervention for anaphylaxis. The causative agent is already introduced, and the systemic immune response is activated. While stopping the infusion is necessary to prevent further exposure, merely slowing it will not halt the progression of the severe hypersensitivity reaction or reverse the physiological changes occurring. The infusion should be stopped immediately.

Choice D rationale

Administering Diphenhydramine 50 mg intramuscularly Stat is appropriate. Diphenhydramine is an H1-receptor antagonist that blocks histamine's effects, thereby reducing vascular permeability, bronchoconstriction, and pruritus associated with anaphylaxis. The intramuscular route ensures rapid systemic absorption, providing a quicker therapeutic effect compared to oral administration in an acute setting.

Choice E rationale

Calling a rapid response team is critical for managing anaphylactic shock. This activates a multidisciplinary team with advanced skills and resources (e.g., physicians, respiratory therapists, critical care nurses) to provide immediate, coordinated, and escalated medical care. Their expertise is essential for managing a rapidly deteriorating patient and implementing advanced life support measures.

Choice F rationale

Preparing for administration of Epinephrine is paramount. Epinephrine is the first-line treatment for anaphylaxis due to its alpha-1 adrenergic effects (vasoconstriction, increasing blood pressure and reducing edema) and beta-2 adrenergic effects (bronchodilation, alleviating respiratory distress). It rapidly counteracts the widespread vasodilation and bronchoconstriction that characterize severe anaphylactic reactions.