The nurse initiates an IV infusion of piperacillin-tazobactam. The patient soon complains of shortness of breath, pruritus, and hives. Which of the following should the nurse do first?

Explanation

• The nurse's first priority is always assessing the patient's airway.

• However, looking closer at this scenario, the patient is able to talk to the nurse; therefore, the airway must be patent.

• The nurse should recognize that the patient is having an anaphylactic reaction and administer epinephrine first. This will prevent the airway from closing.

• Incorrect: Diphenhydramine should be given if the patient is having a mild allergic reaction.

• Incorrect: Blood pressure should be monitored, but after the immediate threat is handled.

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