The nurse is caring for a child experiencing anaphylactic shock. The nurse should prioritize administering
The nurse is caring for a child experiencing anaphylactic shock. The nurse should prioritize administering
A. nasal cannula oxygen.
[7%]
B. intramuscular (IM) epinephrine.
[83%]
C. intravenous (IV) dexamethasone.
[2%]
D. intravenous (IV) diphenhydramine.
[8%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Respiratory
Client Need
Test Plan
Physiological Adaptation
Related Topic
Medical Emergencies
Item Type
Item Type
Analysis
Explanation
Choice B is correct. Anaphylactic shock is a life-threatening allergic reaction that can lead to rapid and severe airway constriction, hypotension, and other systemic symptoms. The first-line treatment of anaphylactic shock is IM epinephrine. The administration of this medication should not be delayed because the cascade of the shock can be alleviated by antagonizing histamine, which is in excess during anaphylactic shock. Epinephrine is preferred over diphenhydramine because epinephrine targets the histamine receptors in the airway.
Choice A is incorrect. Additionally, nasal cannula oxygen is not used in anaphylactic shock because it would not deliver the high flow of oxygen that a nonrebreather can provide. Thus, if oxygen is necessary, it should be delivered using a high-flow, nonrebreather mask at 90% to 100%.
Choice C is incorrect. Dexamethasone is a corticosteroid that can help reduce inflammation and allergic reactions. While it is a component of an anaphylaxis treatment plan, it is not the initial priority.
Choice D is incorrect. Diphenhydramine (Benadryl) is an antihistamine that can help relieve itching and hives associated with allergic reactions. It is not the first-line treatment for anaphylactic shock.
Additional Info
✓ Anaphylactic shock is a medical emergency with the cardinal symptoms of hypotension, respiratory distress, and laryngeal edema.
✓ The nurse must intervene early and aggressively to prevent clinical decline
✓ This includes removing the causative agent (if possible), administering prescribed IM epinephrine and crystalloid fluids to restore circulating volume
✓ Other treatments include high-flow oxygen via nonrebreather, corticosteroids, and diphenhydramine
