HESI RN EXIT CASE STUDY: CONGENITAL HEART DISEASE
1. Which clinical manifestations would the nurse expect to assess in an
infantdiagnosed with ventricular septal defect (VSD)
Answer: Tachypnea and grunting with intercostal and subcostal retractions
2. The nurse understands that a child is experiencing heart failure when
whichsymptoms are found
Answer: -Cool extremities.
-Peripheral edema.
-Nasal Flaring.
3. Which statement by Joan supports Timmy's diagnosis of CHF
Answer: "Timmynever seems to get full even when I breastfeed him for a
long time."
4. What should the nurse include when teaching Timmy's parents
about post-procedure care
Answer: Explain that they will need to hold Timmy in the proneposition
after the procedure.
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, 5. Which action should the nurse implement
Answer: Notify the cardiologist and do notallow Thomas to sign the permit.
6. Which nursing intervention must be included in Timmy's plan of care
relatedto this diagnosis
Answer: Assess the infant's peripheral pulses and capillary refill time.
7. Which response is most important for the nurse to educate the parents
about feeding
Answer: "Your son will be able to suck more easily and will not be so tired
from feeding."
8. Which member of the perinatal care team will best be able to assist
thenurse
Answer: Certified Lactation Consultant (CLC).
9. Which measurement will be most useful to evaluate Timmy's
response toeach feeding technique
Answer: SaO2 changes during feeding.
10. Which intervention should the nurse implement prior to
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1. Which clinical manifestations would the nurse expect to assess in an
infantdiagnosed with ventricular septal defect (VSD)
Answer: Tachypnea and grunting with intercostal and subcostal retractions
2. The nurse understands that a child is experiencing heart failure when
whichsymptoms are found
Answer: -Cool extremities.
-Peripheral edema.
-Nasal Flaring.
3. Which statement by Joan supports Timmy's diagnosis of CHF
Answer: "Timmynever seems to get full even when I breastfeed him for a
long time."
4. What should the nurse include when teaching Timmy's parents
about post-procedure care
Answer: Explain that they will need to hold Timmy in the proneposition
after the procedure.
1/3
, 5. Which action should the nurse implement
Answer: Notify the cardiologist and do notallow Thomas to sign the permit.
6. Which nursing intervention must be included in Timmy's plan of care
relatedto this diagnosis
Answer: Assess the infant's peripheral pulses and capillary refill time.
7. Which response is most important for the nurse to educate the parents
about feeding
Answer: "Your son will be able to suck more easily and will not be so tired
from feeding."
8. Which member of the perinatal care team will best be able to assist
thenurse
Answer: Certified Lactation Consultant (CLC).
9. Which measurement will be most useful to evaluate Timmy's
response toeach feeding technique
Answer: SaO2 changes during feeding.
10. Which intervention should the nurse implement prior to
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