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What is the priority action for a nurse when a patient shows signs of anaphylaxis?
Asked on Feb 03, 2026
Answer
When a patient shows signs of anaphylaxis, the nurse's priority action is to ensure airway patency and administer epinephrine immediately, as anaphylaxis is a life-threatening emergency requiring rapid intervention. Recognizing symptoms such as difficulty breathing, swelling, and hives is crucial for prompt treatment.
Example Nursing Steps:
- Step 1 – Assess the patient's airway, breathing, and circulation (ABCs) immediately.
- Step 2 – Administer epinephrine as per protocol and ensure emergency medical support is on the way.
- Step 3 – Monitor vital signs, provide oxygen if needed, and document the patient's response and interventions.
Additional Comment:
- Anaphylaxis requires rapid identification and treatment to prevent severe complications or death.
- Always follow institutional protocols for emergency medication administration.
- After stabilizing the patient, identify and remove the trigger if possible.
- Prepare for potential escalation of care, including advanced airway management.
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