NUR 265
FINAL EXAM REVIEW
Medical-Surgical Nursing
Galen College of Nursing
, EXAM 4 REVIEW
1. Priority assessment/intervention for a patient who had an allergic reaction to a vaccine
Page 365 chart 20-3
Emergency care of the patient with anaphylaxis
Immediately assess the respiratory status, airway, and oxygen saturation of patients
who show any symptoms of an allergic reaction
Call the RRT
Ensure that intubation and tracheotomy equipment is ready
Apply oxygen using a high-flow, nonrebreather mask at 90% to 100%
Immediately discontinue the IV drug or infusing solution of a patient having an
anaphylactic reaction to that drug or solution. DO NOT discontinue the IV, but
change the IV tubing and hang NS
If the patient doesn’t have an IV, start one immediately and run NS
Be prepared to administer epinephrine IV or IM
epinephrine 1:1000 concentration, 0.3 to 0.5 mL IV push or IM
Repeat drug administration as needed every 5 to 15 minutes until the patient
responds
Keep the HOB elevated about 10 degrees if hypotension is present; if BP is normal,
elevate the HOB to 45 degrees or higher to improve ventilation
Raise the feet and legs
Stay with the patient
Reassure the patient that the appropriate interventions are being instituted
2. Typical signs and symptoms of an anaphylactic reaction
Page 364 chart 20-2
Anaphylaxis
Clinical criteria 1: onset within minutes to hours of skin or mucous membrane
problems involving swollen lips, tongue, soft palate, uvula; widespread hives;
pruritis; or flushing along with any one of these new-onset symptoms:
respiratory distress or ineffectiveness
dyspnea
bronchospasms
wheezes
stridor
hypoxia
cyanosis
peak expiratory rate flow lower than the patient’s usual rate
hypotension or any indication of reduced perfusion resulting in organ
dysfunction
This study source was downloaded by 100000902171055 from CourseHero.com on 11-26-2025 19:20:05 GMT -06:00
https://www.coursehero.com/file/71360710/EXAM-4-REVIEWdocx/
FINAL EXAM REVIEW
Medical-Surgical Nursing
Galen College of Nursing
, EXAM 4 REVIEW
1. Priority assessment/intervention for a patient who had an allergic reaction to a vaccine
Page 365 chart 20-3
Emergency care of the patient with anaphylaxis
Immediately assess the respiratory status, airway, and oxygen saturation of patients
who show any symptoms of an allergic reaction
Call the RRT
Ensure that intubation and tracheotomy equipment is ready
Apply oxygen using a high-flow, nonrebreather mask at 90% to 100%
Immediately discontinue the IV drug or infusing solution of a patient having an
anaphylactic reaction to that drug or solution. DO NOT discontinue the IV, but
change the IV tubing and hang NS
If the patient doesn’t have an IV, start one immediately and run NS
Be prepared to administer epinephrine IV or IM
epinephrine 1:1000 concentration, 0.3 to 0.5 mL IV push or IM
Repeat drug administration as needed every 5 to 15 minutes until the patient
responds
Keep the HOB elevated about 10 degrees if hypotension is present; if BP is normal,
elevate the HOB to 45 degrees or higher to improve ventilation
Raise the feet and legs
Stay with the patient
Reassure the patient that the appropriate interventions are being instituted
2. Typical signs and symptoms of an anaphylactic reaction
Page 364 chart 20-2
Anaphylaxis
Clinical criteria 1: onset within minutes to hours of skin or mucous membrane
problems involving swollen lips, tongue, soft palate, uvula; widespread hives;
pruritis; or flushing along with any one of these new-onset symptoms:
respiratory distress or ineffectiveness
dyspnea
bronchospasms
wheezes
stridor
hypoxia
cyanosis
peak expiratory rate flow lower than the patient’s usual rate
hypotension or any indication of reduced perfusion resulting in organ
dysfunction
This study source was downloaded by 100000902171055 from CourseHero.com on 11-26-2025 19:20:05 GMT -06:00
https://www.coursehero.com/file/71360710/EXAM-4-REVIEWdocx/
