HESI RN EXIT CASE STUDY: CONGENITAL HEART DISEASE

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HESI RN EXIT CASE STUDY: CONGENITAL HEART DISEASE

• Which clinical manifestations would the nurse expect to assess in an infant

diagnosed with ventricular septal defect (VSD)

ANS: Tachypnea and grunting with intercostal and subcostal retractions

• The nurse understands that a child is experiencing heart failure when which

symptoms are found

ANS: -Cool extremities.

-Peripheral edema.-Nasal Flaring.

• Which statement by Joan supports Timmy's diagnosis of CHF

ANS: "Timmy never seems to get full even when I breastfeed him for a long

time."

• What should the nurse include when teaching Timmy's parents about

post-procedure care

ANS: Explain that they will need to hold Timmy in the prone position after the

procedure.

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• Which action should the nurse implement

ANS: Notify the cardiologist and do not allow Thomas to sign the permit.

• Which nursing intervention must be included in Timmy's plan of care related

to this diagnosis

ANS: Assess the infant's peripheral pulses and capillary refill time.

• Which response is most important for the nurse to educate the parents

about feeding ANS: "Your son will be able to suck more easily and will not be so tired from feeding."

• Which member of the perinatal care team will best be able to assist the

nurse

ANS: Certified Lactation Consultant (CLC).

• Which measurement will be most useful to evaluate Timmy's response to

each feeding technique

ANS: SaO2 changes during feeding.

• Which intervention should the nurse implement prior to administering

the first dose of digoxin (Lanoxin) to Timmy

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