A patient presents to the ED with a suspected allergic reaction. The patient is experiencing laryngeal edema causing obstruction and is demonstrating retractions in the neck during inspirations. Which of the following is the nurse's priority intervention?
a) Apply 100% oxygen via a face mask.
b) Prepare for immediate tracheostomy.
c) Prepare to administer subcutaneous epinephrine and corticosteroids.
d) Prepare for endotracheal intubation with mechanical ventilation.
Answer: c) Prepare to administer subcutaneous epinephrine and corticosteroids.
Explanation:
The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspirations and is an ominous sign of impending respiratory distress. The patient's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a patient with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the patient's laryngeal edema is the administration of the medications. pg.551
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