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
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Seal non-washable items in a plastic bag for 2 days."
Items should be sealed for 14 days, not 2 days, to ensure lice and nits die due to lack of air.
B. "Soak hairbrushes in boiling water for 10 minutes."
This is an effective way to kill lice and nits on combs and brushes.
C. "Apply permethrin 1 percent cream rinse every day for 5 days."
Permethrin should be applied once, and reapplication is recommended in 7 to 10 days if needed—not daily.
D. "After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
Items should be dried on a high heat setting to kill lice and nits.
Correct Answer is B
Explanation
A. "Honor the child's request if they hold their breath.":
Breath-holding spells during tantrums are usually harmless. Giving in reinforces negative behavior.
B. "Establish a structured daily routine for the child."
Structured routines help toddlers feel secure and can reduce the frequency of tantrums by making expectations predictable.
C. "Place the child in their room alone until the temper tantrum ends.":
Isolation may frighten the child. A safe space nearby while supervising is better.
D. "Comfort the child during the temper tantrum.":
Comforting during the tantrum can reinforce the behavior. Instead, calmly wait until the tantrum subsides before offering comfort.
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