Today’s NCLEX-RN® question of the day focuses on a nurse who is tending to a patient who has developed anaphylaxis due to shellfish consumption. What is the initial intervention the nurse should prioritize in this situation? Can you figure it out?

The nurse is caring for a patient experiencing anaphylaxis after eating shellfish. Which intervention should the nurse perform first?

A. Place a peripheral IV and start IV fluids

B. Elevate the head of the bed

C. Administer epinephrine intramuscularly

D. Provide emotional support to the patient Scroll down for the correct answer!

The correct answer to today’s NCLEX-RN® Question is…

C. Administer epinephrine intramuscularly

Rationale: Administering epinephrine should be performed first as it will stop the release of chemical mediators that cause bronchoconstriction, systemic vasodilation, and increased vascular permeability.

Major Takeaway

The nurse caring for a patient experiencing anaphylaxis secondary to an allergic reaction should use clinical judgment to prioritize nursing interventions. Administering epinephrine helps to treat the cause of the anaphylaxis. Once the bronchoconstriction, systemic vasodilation, and increased vascular permeability are addressed with epinephrine, interventions like IV fluids, emotional support, and repositioning the patient to promote breathing are performed.

Incorrect answer explanations

A. Place a peripheral IV and start IV fluids

Rationale: IV fluids should be administered to replace intravascular volume, but this is not the first intervention that should be performed.

B. Elevate the head of the bed

Rationale: Elevating the head promotes increased lung expansion, but this is not the first intervention that should be performed.

D. Provide emotional support to the patient

Rationale: Patients with anaphylaxis will likely need emotional support, but this is not the first intervention that should be performed.

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