A patient with iron poisoning is receiving infusion of deferoxamine intravenously. Suddenly patient feels flushing of face, urticaria, hypotension and headache. What would be the initial nursing action?

Appeared in: NORCET 3 - 2022 (Shift-1)

Explanation

The patient's symptoms (flushing, urticaria, hypotension, headache) are classic signs of a severe, systemic adverse reaction to an IV medication.
The absolute first priority in any acute IV infusion reaction is to stop the administration of the causative agent.
This action prevents further exposure to the drug, thereby halting the progression of the potentially life-threatening reaction.
All other actions, such as assessing vital signs and notifying the physician, are secondary to stopping the infusion.

Option B: Continuing the infusion would deliver more of the drug causing the reaction, leading to a more severe and potentially fatal outcome.
Option C: While assessing vital signs is a high-priority action, it is not the initial action. The cause of the problem must be eliminated first to prevent further harm. The assessment should be performed immediately after stopping the infusion.
Option D: Informing the physician is essential but not the first action. The nurse must first intervene to stabilize the patient and ensure safety. Reporting to the physician occurs after stopping the infusion and performing a rapid assessment.

Clinical Relevance

Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Prioritization of nursing actions during an acute intravenous (IV) medication reaction in acute care settings.
Recognizing and acting immediately on signs of an IV infusion reaction is a critical patient safety competency for nurses. The principle is always 'Stop, Assess, Notify'.
Rapid infusion of deferoxamine is known to cause hypotension, flushing, and rash (an 'anaphylactoid' reaction), which is why it is typically administered slowly over several hours.
What if? If the patient only reported mild, localized itching at the IV site without systemic symptoms, the nurse's initial action would be to slow the infusion rate and assess the site thoroughly before deciding to stop it completely and notifying the provider. However, with systemic signs like hypotension, stopping is the only correct initial action.

How to Approach the Question

First, identify the core problem in the clinical scenario. The patient is having an acute, systemic reaction to an IV drug.
Next, recognize that this is a priority-setting question, asking for the 'initial' action.
Apply the fundamental principle of patient safety: remove the source of harm first. In this case, the harm is the drug being infused.
Evaluate the options based on this principle. 'Stop the Infusion' is the only option that directly removes the cause of the problem.
The other options, 'Assess the vital signs' and 'Inform to the physician', are necessary subsequent actions, but they do not take precedence over stopping the infusion.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing actions during an acute intravenous (IV) medication reaction.
Stem keywords: iron poisoning, deferoxamine, intravenously, flushing, urticaria, hypotension, headache
Lead-in keywords: initial nursing action
Clinical cues: The combination of flushing, urticaria, and hypotension strongly suggests a systemic hypersensitivity or anaphylactoid reaction, which is a medical emergency.

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 127-129

E6 Nursing Fundamentals Taylor p. 835-837

Practise the full NORCET 3 - 2022 (Shift-1)

Attempt every question from this paper in a timed mock, then review the full solution for each one.