Given the following vital signs, which should the nurse address first in the patient?

Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.

A. Stop the antibiotic infusion immediately and notify the healthcare provider.

• Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.

B. Apply a cool compress to the itchy areas and monitor for further reactions.

• Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.

C. Administer diphenhydramine (Benadryl) as a first-line treatment.

• Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.

D. Assess the client’s throat for swelling and encourage them to drink water.

• Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.