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?

Sharp pain in middle of the chest

Severe itching of the hands

Distended neck veins

Decreased temperature

Answer and Explanation

The Correct Answer is C

A. Sharp pain in middle of the chest:

Chest pain can occur in multiple transfusion reactions, including hemolytic reactions—not specific to air embolism alone.

B. Severe itching of the hands:

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

C. Distended neck veins

Distended neck veins, dyspnea, and chest pain are signs of an air embolism, a life-threatening emergency.

D. Decreased temperature:

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

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Correct Answer is C

Explanation

A. Steatorrhea

This refers to fatty, foul-smelling stools and is associated with malabsorption syndromes (e.g., celiac disease), not UTIs.

B. Jaundice

Jaundice is typically associated with liver or hemolytic conditions. It is not a symptom of a urinary tract infection.

C. Incontinence

In a toilet-trained toddler, new or increased episodes of incontinence may indicate a UTI. Toddlers may have difficulty expressing pain or urinary urgency, so regression in toilet habits is often a key indicator.

D. Rebound tenderness

Rebound tenderness indicates peritoneal irritation, seen in conditions like appendicitis—not in uncomplicated UTIs.

A. New heart murmur B. Weight gain C. Bradycardia D. Decreased body temperature

Correct Answer is A

Explanation

A. New heart murmur:

A new or changing heart murmur is a common clinical manifestation of infective endocarditis due to valve damage.

B. Weight gain:

Weight loss, not weight gain, is more typical due to decreased appetite and systemic illness.

C. Bradycardia:

Tachycardia (increased heart rate) is more commonly associated with infection, not bradycardia.

D. Decreased body temperature:

Fever (elevated body temperature), not hypothermia, is expected in infective endocarditis.

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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?

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