Difficulty: Medium
Average Score: 79%
Simulated
A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions?
Correct answer
A,B,C,D,E,F
Rationale
The correct order is A, B, C, D, E, F. First, assessing the client's airway (A) is crucial in a potentially life-threatening situation like anaphylaxis. This allows the nurse to determine if there is any obstruction that needs immediate intervention. Next, calling the emergency response team (B) ensures timely and specialized care. Providing high-flow oxygen (C) supports oxygenation and helps stabilize the client. Initiating IV access (D) prepares for medication administration. Administering IV epinephrine (E) is the primary treatment for anaphylaxis to counteract the severe allergic reaction. Lastly, administering IV antihistamines (F) can help further reduce allergic symptoms. The other choices are incorrect as they do not address the immediate life-threatening nature of anaphylaxis and do not follow the standard protocol for managing this condition effectively.