Which of the following represents signs of anaphylaxis and a recommended initial nursing intervention?

• A. Nausea and headache only
• B. Rapid onset of hives, swelling, wheezing, dyspnea, hypotension; immediate actions: call for help, administer epinephrine if prescribed, secure airway, start IV access and provide oxygen.
• C. Dizziness with fainting; monitor
• D. Sneezing with runny nose; antihistamines

Answer: (B)

Anaphylaxis is a rapid, life-threatening systemic allergic reaction. The key signs involve multiple body systems: the skin may show widespread hives or swelling, the airways can become constricted leading to wheezing and dyspnea, and the circulation can drop, causing hypotension. The most appropriate nursing response is to act immediately by calling for help, administering epinephrine as prescribed, securing the airway, starting IV access, and providing oxygen. Epinephrine is the critical first-line treatment because it rapidly reverses airway swelling and improves blood pressure and airflow, buying time for further care. Ensuring airway protection and IV access prepares for additional treatments and fluids, while oxygen helps correct any low oxygen levels. The other options miss the urgent, multi-system presentation of anaphylaxis and the necessity of prompt, life-saving interventions.