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A nurse is assessing a child who has an acute kidney injury. Which of the following clinical manifestations should the nurse expect?

Decreased respiratory rate

Polyuria

Hyperactivity

Edema

Answer and Explanation

The Correct Answer is D

A. Decreased respiratory rate:

Respiratory rate may increase due to fluid overload and acidosis, but decreased rate is not typical.

B. Polyuria:

In the initial phase of AKI, oliguria (low urine output) is common, not polyuria.

C. Hyperactivity:

Hyperactivity is unrelated to AKI; lethargy and confusion are more likely.

D. Edema:

Edema occurs due to fluid retention from decreased urine output in acute kidney injury (AKI).

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Correct Answer is A

Explanation

A. Sharp pain in middle of the chest:

Air embolism commonly presents with sudden substernal chest pain due to obstruction of pulmonary blood flow by air bubbles. This is a hallmark early sign, along with dyspnea, cyanosis, and anxiety.

B. Severe itching of the hands:

Itching is a sign of an allergic reaction, not air embolism.

C. Distended neck veins

Jugular vein distension (JVD) may occur with air embolism due to impaired venous return and right-sided heart strain. However, the classic and most indicative early finding is sharp substernal chest pain.

D. Decreased temperature:

Hypothermia is not a sign of air embolism. Blood products can sometimes lower body temperature, but that is unrelated to embolism.

A. "Gently put the tubes back into the child's ears." B. "Bring the child to the emergency department immediately." C. "Notify the provider that the tubes have fallen out." D. "The tubes are sutured in place and must be surgically removed."

Correct Answer is C

Explanation

A. "Gently put the tubes back into the child's ears."

Parents should not attempt to reinsert tubes, as this could cause damage.

B. "Bring the child to the emergency department immediately."

This is unnecessary unless the child has acute symptoms like severe ear pain, bleeding, or signs of infection.

C. "Notify the provider that the tubes have fallen out."

Tympanostomy tubes can sometimes fall out spontaneously. The provider needs to assess whether reinsertion is necessary based on the child's history of infections and hearing concerns.

D. "The tubes are sutured in place and must be surgically removed."

Tubes are not sutured. They typically fall out on their own as the ear heals.

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A nurse is assessing a child who has an acute kidney injury. Which of the following clinical manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who has received the first 50 mL of a blood transfusion. Which of the following findings indicates that the child might be experiencing an air embolism?

Correct Answer is A

Explanation

A nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following placement of tympanoplasty tubes. The parent asks the nurse, "What should I do if the tubes fall out?" Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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