ATI nur 270 Paediatrics gigu Proctored Exam
A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 148 beats/minute. 02 saturation is 86%, and the child is dyspneic. Which action is the nurse's priority?
Explanation & Rationale
A. Administering Benadryl may help with allergic reactions but is not the immediate priority when the patient is showing signs of severe hypotension and respiratory distress. B. Applying ice to the site may help with local swelling but does not address the systemic reaction the child is experiencing. C. Giving epinephrine is the priority action as it counteracts the anaphylactic reaction, improves blood pressure, and alleviates respiratory distress. D. Determining if the sting is in situ is less critical than addressing the child's life-threatening symptoms.
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