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 A
Explanation
A. Preschoolers believe their illness is punishment for their misbehavior.
This is developmentally appropriate thinking in preschoolers (ages 3–6), who may view illness or death as a consequence of wrongdoing.
B. Preschoolers are interested in what happens to the body after death.
This type of abstract thinking is more typical of school-age children, not preschoolers.
C. Adolescents worry more about death than the physical changes that can occur as a result of the illness.
Adolescents are often more concerned with body image, independence, and peer acceptance than the concept of death itself.
D. Toddlers personify death as being a type of monster.
Toddlers do not fully understand the concept of death and typically do not personify it.
Correct Answer is ["C","D"]
Explanation
Findings that indicate a developmental delay:
Language: uses one word sentences, can say 5 words- At age 2, toddlers are expected to use at least two-word phrases and have a vocabulary of about 50 words. This finding suggests a delay in expressive language development.
Play: does not notice when others are upset- At this age, toddlers begin to show empathy or awareness of others' emotions. Not noticing when others are upset could indicate a delay in social-emotional development.
Rationale for incorrect findings:
Fine motor: rotates utensils to bring them to their mouth- This is an age-appropriate fine motor skill.
Gross motor: scoots on bottom up and down stairs- Although some toddlers may walk up stairs by 2 years, scooting is still within developmental range.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.