The nurse is assessing a client with acute kidney injury and hears the following sound when auscultating the lungs. For what complication does the nurse plan care? (Click the media button to hear the audio clip.)
a. ac tamponade
b. Pericarditis
c. Pulmonary edema
d. Myocardial Infarction
B
The sound heard is a pericardial friction rub. This is heard in pericarditis because the pericardial sac becomes inflamed from uremic toxins. Other manifestations include low-grade fever, tachy-cardia, and chest pain. A tamponade would manifest as muffled heart tones. Pulmonary edema would manifest with crackles in the lungs. A myocardial infarction may or may not have abnor-mal chest sounds associated with it.
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