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What is the priority nursing action for a patient showing signs of anaphylaxis?
Asked on Feb 19, 2026
Answer
In a patient showing signs of anaphylaxis, the priority nursing action is to ensure airway patency and administer epinephrine immediately, as anaphylaxis is a life-threatening allergic reaction that can cause airway obstruction and cardiovascular collapse.
Example Nursing Steps:
- Step 1 – Assess the patient's airway, breathing, and circulation (ABCs) immediately.
- Step 2 – Administer intramuscular epinephrine as per emergency protocol.
- Step 3 – Monitor vital signs, prepare for advanced airway management if needed, and document the event and interventions.
Additional Comment:
- Anaphylaxis requires rapid identification and intervention to prevent severe complications.
- After epinephrine administration, continue to monitor for biphasic reactions and provide supportive care.
- Communicate with the healthcare team for further management and potential transfer to a higher level of care.
- Document all assessments, interventions, and patient responses accurately in the medical record.
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