A nurse is caring for a client who has developed an allergic reaction to a medication. Which of the following actions should the nurse take first?

Explanation: Carrying an epinephrine auto-injector is a crucial self-management strategy for individuals with known allergies. In case of an allergic reaction, epinephrine can be administered promptly to counteract severe symptoms and potentially prevent anaphylaxis. This response demonstrates the client's understanding of the importance of being prepared to manage allergic reactions.

A) "I will avoid all potential allergens to prevent any reaction."

While avoiding known allergens is an essential aspect of managing allergies, it is often challenging to avoid all potential allergens. Some allergens may be difficult to identify or encounter unexpectedly. Carrying an epinephrine auto-injector provides a more comprehensive approach to self-management.

C) "I will take antihistamine medication every day to prevent reactions."

Antihistamines are primarily used for relieving symptoms of allergic reactions, such as itching or congestion, rather than preventing reactions. Taking antihistamines every day is not the recommended approach for preventing allergic reactions.

D) "I will self-administer corticosteroid injections during allergic reactions."

Corticosteroid injections are generally administered by healthcare professionals and are not intended for self-administration during allergic reactions. Corticosteroids may be part of the treatment plan for severe allergic reactions but are typically prescribed and administered under medical supervision.

Assess the client's respiratory status and oxygen saturation. This is the correct answer because the nurse should follow the ABC (airway, breathing, circulation) priority-setting framework when caring for a client who has an allergic reaction. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis, which is a life-threatening emergency. The other actions are also important, but they are not the first priority.

A) Administer an antihistamine as prescribed. This is an incorrect answer because although administering an antihistamine can help reduce the symptoms of an allergic reaction, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.

B) Stop the medication infusion and disconnect the IV tubing. This is an incorrect answer because although stopping the medication infusion and disconnecting the IV tubing can prevent further exposure to the allergen, it is not the first action that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.

D) Notify the provider and document the incident. This is an incorrect answer because although notifying the provider and documenting the incident are important steps in managing an allergic reaction, they are not the first actions that the nurse should take. The nurse should first assess the client's respiratory status and oxygen saturation to determine if they are in respiratory distress or have signs of anaphylaxis.