Anaphylaxis — NCLEX Cheat Sheet
Epinephrine IM = first drugAlso known as: severe allergic reaction · allergic shock · anaphylactic shock · life-threatening allergy · allergy emergency
Use this quick-reference guide to spot, treat, and prevent Anaphylaxis on the NCLEX. Keep it handy during review and on exam day!
🩺📒 The 1-minute cheat sheet
🩺 Signs
- Stridor, wheeze, throat swelling
- Hypotension, tachycardia, shock
- Hives, angioedema, anxiety
✅ Do First
- Epinephrine IM lateral thigh STAT
- Stop allergen, call rapid response
- Airway first → O2, prepare intubation
🧪 Meds
- Then antihistamine, steroids, fluids
- Repeat epi q5-15 min PRN
🎓 Teach
- Carry EpiPen, MedicAlert bracelet
📚 Anaphylaxis — full study notes
The cheat sheet above is your quick recall card. These notes go deeper — what it is, what to do first, what must be reported, and what to teach.
Key points
Understand these first- Onset is sudden, usually within minutes of exposure, and rapidly worsening.
- Airway and breathing signs include throat tightness, stridor, hoarseness, wheezing, and dyspnea.
- Circulatory signs include hypotension, tachycardia, dizziness, and impending sense of doom from vasodilation.
- Skin signs include urticaria (hives), flushing, pruritus, and angioedema of the lips, tongue, and face.
- GI symptoms such as cramping, nausea, vomiting, and diarrhea may accompany the reaction.
- A biphasic reaction can recur hours later, so observation after stabilization is required.
Nursing priorities
What to do, in order- Stop the offending allergen or infusion immediately and call for help.
- Administer intramuscular epinephrine into the lateral thigh without delay; this is the priority drug.
- Maintain a patent airway, give high-flow oxygen, and prepare for possible intubation.
- Establish IV access and give rapid isotonic fluids for hypotension; lay the patient flat with legs elevated unless dyspneic.
- Give adjuncts as ordered (antihistamines, corticosteroids, bronchodilators) and monitor continuously.
Red flags — report now
Escalate immediately- Stridor, hoarseness, or tongue/lip swelling signals impending airway loss; act and escalate now.
- Hypotension with weak pulse indicates anaphylactic shock requiring immediate epinephrine and fluids.
- Never delay epinephrine to give antihistamines or steroids first; epinephrine is always first.
- Watch for a biphasic recurrence and keep the patient under observation even after improvement.
Labs & values
Numbers to know- Serum tryptase may be elevated (supports diagnosis but is not used to delay treatment)
- Oxygen saturation goal at least 94%
Patient teaching
What patients must know- Carry two epinephrine auto-injectors at all times and use one into the outer thigh at the first sign of a severe reaction, then call emergency services.
- Always seek emergency care after using epinephrine because a second-phase reaction can occur.
- Strictly avoid the known trigger, read food and product labels, and wear a medical-alert bracelet.
❓ Anaphylaxis: NCLEX FAQs
What are the priority nursing interventions for Anaphylaxis?
Stop the offending allergen or infusion immediately and call for help. Administer intramuscular epinephrine into the lateral thigh without delay; this is the priority drug. Maintain a patent airway, give high-flow oxygen, and prepare for possible intubation. Establish IV access and give rapid isotonic fluids for hypotension; lay the patient flat with legs elevated unless dyspneic.
What are the warning signs of Anaphylaxis a nurse must report?
Stridor, hoarseness, or tongue/lip swelling signals impending airway loss; act and escalate now. Hypotension with weak pulse indicates anaphylactic shock requiring immediate epinephrine and fluids. Never delay epinephrine to give antihistamines or steroids first; epinephrine is always first. Watch for a biphasic recurrence and keep the patient under observation even after improvement.
What do I need to know about Anaphylaxis for the NCLEX?
Onset is sudden, usually within minutes of exposure, and rapidly worsening. Airway and breathing signs include throat tightness, stridor, hoarseness, wheezing, and dyspnea. Circulatory signs include hypotension, tachycardia, dizziness, and impending sense of doom from vasodilation. Skin signs include urticaria (hives), flushing, pruritus, and angioedema of the lips, tongue, and face.
What patient teaching is important for Anaphylaxis?
Carry two epinephrine auto-injectors at all times and use one into the outer thigh at the first sign of a severe reaction, then call emergency services. Always seek emergency care after using epinephrine because a second-phase reaction can occur. Strictly avoid the known trigger, read food and product labels, and wear a medical-alert bracelet.
Quick Tip
Onset is sudden, usually within minutes of exposure, and rapidly worsening.
📖 Related Topics
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