A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?
Explanation & Rationale
A. Consulting an allergy specialist: While referral to an allergy specialist is important for long-term management and identification of triggers, it is not the immediate priority during an acute allergic reaction with airway compromise. B. Assessing the client's neurologic status: Neurologic assessment is part of a comprehensive evaluation, but in the context of wheezing, tongue swelling, and hives, airway and cardiovascular stability take precedence over neurologic checks. C. Administering epinephrine: The client is exhibiting signs of anaphylaxis, including airway obstruction (swollen tongue) and respiratory distress (wheezing). Immediate administration of epinephrine is the priority intervention to prevent life-threatening airway compromise and shock. D. Determining the cause of the hives: Identifying triggers is important for preventing future allergic reactions, but during an acute anaphylactic event, addressing the airway and circulatory status with epinephrine takes precedence over determining the cause.