A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection.
Which of the following findings should the nurse identify as a manifestation of pertussis? - Dry, hacking
cough
...
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection.
Which of the following findings should the nurse identify as a manifestation of pertussis? - Dry, hacking
cough
Rationale: The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This
disease usually begins with indications of an upper respiratory tract infection, which includes a dry,
hacking cough that is sometimes more severe at night.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following
manifestations should alert the nurse to a possible hemolytic transfusion reaction? - Flank pain
Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an
indication of a hemolytic reaction to the blood transfusion.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child
suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication
infusion, which of the following medications should the nurse administer first? - Epinephrine
Rationale: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to
evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis.
Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood
vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following
statements by the guardian indicates an understanding of the teaching? - "I should secure the car seat
using lower anchors and tethers instead of the seat belt."
R
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