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A patient is experiencing anaphylaxis after receiving an antibiotic. Which interventions should the nurse prioritize to address this condition?
(Select All that Apply.)

Administer epinephrine intramuscularly

Start intravenous access for fluid resuscitation.

Provide supplemental oxygen to the patient.

Administer corticosteroids immediately.

Place the patient in a supine position with legs elevated.

Administer oral antihistamines.

Ensure the patient has a patent airway.

Encourage oral fluid intake to counteract hypotension.

Monitor the patient's skin for rashes.

Answer and Explanation

Correct Answer : A,B,C,G

A.   Administering epinephrine intramuscularly is the first-line treatment for anaphylaxis, as it counteracts the effects of histamine and reduces swelling.
B.   Starting intravenous access allows for fluid resuscitation and the administration of medications like epinephrine or corticosteroids.
C.   Providing supplemental oxygen is necessary to support the patient's breathing and improve oxygenation during an anaphylactic reaction.
D.   Corticosteroids may be used later to reduce inflammation, but they are not first-line treatments for anaphylaxis.
E.   Placing the patient in a supine position with legs elevated may be helpful for circulation, but it is not the priority over administering epinephrine.

F.   Oral antihistamines are not effective in the acute management of anaphylaxis, which requires immediate action.
G.   Ensuring the patient's airway is patent is the top priority, as airway compromise can occur rapidly during anaphylaxis.
H.   Encouraging oral fluid intake is not appropriate in this emergency situation, as intravenous fluids are needed.
I.   Monitoring the patient's skin for rashes is important but secondary to managing the airway and circulation.

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Correct Answer is A

Explanation

A. Encouraging deep breaths and using an incentive spirometer can help prevent atelectasis and improve oxygenation after surgery, as it encourages lung expansion.
B. Setting the oxygen flow rate based on subjective breathlessness is not ideal; oxygen should be administered according to established protocols and patient need.
C. Administering oxygen without an order is not appropriate and could lead to oxygen toxicity.
D. The Trendelenburg position is not necessary for oxygenation and could lead to increased pressure on the abdomen and respiratory distress.

A. Flush the NG tube with 60 mL of water before starting the feeding. B. Administer the feeding with the patient lying flat to ensure comfort. C. Increase the feeding rate to ensure the patient receives adequate nutrition. D. Position the patient in a semi-Fowler's position during and after feeding.

Correct Answer is D

Explanation

A. Flushing the NG tube with 60 mL of water before feeding is not sufficient to reduce aspiration risk.
B. Administering the feeding with the patient lying flat increases the risk of aspiration and should be avoided.
C. Increasing the feeding rate could cause discomfort and increase the risk of aspiration if the stomach becomes overdistended.
D. Positioning the patient in a semi-Fowler's position (head of the bed elevated 30 to 45 degrees) reduces the risk of aspiration during and after feeding.

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A patient is experiencing anaphylaxis after receiving an antibiotic. Which interventions should the nurse prioritize to address this condition? (Select All that Apply.)

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A patient is experiencing anaphylaxis after receiving an antibiotic. Which interventions should the nurse prioritize to address this condition?
(Select All that Apply.)