Questions with Complete
Solutions
Denning [Date] [Course title]
, 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? - Correct
Answers 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? - Correct Answers
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? - Correct Answers
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? - Correct Answers "I should
secure the car seat using lower anchors and tethers instead of the seat belt."
Rationale: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure
an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back
rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.