ESTUDYR
NCLEX-RN Case Study: Anaphylactic Shock
Client Scenario
1200 Nurses' Notes: A 28-year-old female is admitted to the medical unit for treatment of a
urinary tract infection (UTI). She has no known drug allergies. The nurse begins the first dose
of IV Cefazolin. Five minutes into the infusion, the client calls the nurse and states, "My
throat feels tight, and I feel like I'm breaking out in a rash."
Physical Assessment:
Respiratory: Visible inspiratory stridor and wheezing audible without a stethoscope.
Client is coughing and gasping for air.
Integumentary: Diffuse erythema and hives (urticaria) noted on the neck and chest.
Angioedema (swelling) of the lips and tongue.
Vital Signs: BP 82/40, HR 132, RR 34, SpO2 86% on Room Air.
Item 1: Recognizing Cues
Question: Click to highlight the findings that indicate a life-threatening systemic reaction.
Findings: 28-year-old female; throat feels tight; inspiratory stridor; Angioedema of the lips
and tongue; BP 82/40; HR 132; SpO2 86%.
Rationale: Stridor and angioedema indicate a compromised airway. A blood pressure of
82/40 and tachycardia (HR 132) signify distributive shock (anaphylaxis), where massive
vasodilation causes a drop in perfusion.
Item 2: Analyzing Cues
Question: The nurse understands that the pathophysiology of this reaction involves which
of the following? (Select All That Apply)
1. ✅Systemic vasodilation causing hypotension.
NCLEX-RN Case Study: Anaphylactic Shock
Client Scenario
1200 Nurses' Notes: A 28-year-old female is admitted to the medical unit for treatment of a
urinary tract infection (UTI). She has no known drug allergies. The nurse begins the first dose
of IV Cefazolin. Five minutes into the infusion, the client calls the nurse and states, "My
throat feels tight, and I feel like I'm breaking out in a rash."
Physical Assessment:
Respiratory: Visible inspiratory stridor and wheezing audible without a stethoscope.
Client is coughing and gasping for air.
Integumentary: Diffuse erythema and hives (urticaria) noted on the neck and chest.
Angioedema (swelling) of the lips and tongue.
Vital Signs: BP 82/40, HR 132, RR 34, SpO2 86% on Room Air.
Item 1: Recognizing Cues
Question: Click to highlight the findings that indicate a life-threatening systemic reaction.
Findings: 28-year-old female; throat feels tight; inspiratory stridor; Angioedema of the lips
and tongue; BP 82/40; HR 132; SpO2 86%.
Rationale: Stridor and angioedema indicate a compromised airway. A blood pressure of
82/40 and tachycardia (HR 132) signify distributive shock (anaphylaxis), where massive
vasodilation causes a drop in perfusion.
Item 2: Analyzing Cues
Question: The nurse understands that the pathophysiology of this reaction involves which
of the following? (Select All That Apply)
1. ✅Systemic vasodilation causing hypotension.
