Emergency Nursing & Triage NCLEX Challenge Exam

Nurse Ejay is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform

Answer to Emergency Nursing & Triage NCLEX Challenge Exam:

In the case of a client who has been stung by a honeybee and is experiencing localized pain and swelling without respiratory distress or other symptoms of anaphylactic shock, the appropriate initial action that the nurse should direct the client to perform is as follows:

1. Remove the Stinger: The nurse should instruct the client to remove the stinger from the skin if it’s still present. This is typically done by scraping the stinger gently with a flat-edged object like a credit card. It’s important not to pinch or squeeze the stinger, as that can release more venom into the skin.
2. Wash the Area: The client should be advised to wash the affected area with soap and water to reduce the risk of infection.
3. Apply a Cold Compress: Instruct the client to apply a cold compress (ice wrapped in a cloth) to the affected area for 15-20 minutes. This can help reduce pain and swelling.
4. Pain Relief: Over-the-counter pain relievers such as ibuprofen or acetaminophen can be recommended to alleviate pain and discomfort. The client should follow the dosing instructions on the medication label.
5. Monitor for Allergic Reactions: Advise the client to monitor their condition for any signs of an allergic reaction or anaphylactic shock, which could include difficulty breathing, swelling of the face or throat, hives, rapid heart rate, or other severe symptoms. If any of these symptoms occur, they should seek immediate medical attention.
6. Rest and Elevate: If the swelling is in an extremity (such as a hand or foot), the client can elevate the affected area to further reduce swelling.
7. Stay Calm: Reassure the client that their symptoms are typical for a bee sting without an allergic reaction and that they are taking appropriate steps for relief.

It’s important to remind the client that bee stings can cause discomfort for a few days, and the swelling and pain should gradually subside. If the client’s condition worsens, or if they experience any signs of an allergic reaction, they should seek immediate medical attention or call emergency services. This initial action plan is for a typical localized reaction to a bee sting, and monitoring for any worsening symptoms is crucial.