HESI RN Case Study: Congenital heart disease
Study online at https://quizlet.com/_hntj6y
1. Which clinical manifestations would the nurse expect to assess in an infant
diagnosed with ventricular septal defect (VSD)?: Tachypnea and grunting with intercostal and
subcostal retractions.
2. The nurse understands that a child is experiencing heart failure when which
symptoms are found?: -Cool extremities.
-Peripheral edema.
-Nasal Flaring.
3. Which statement by Joan supports Timmy's diagnosis of CHF?: "Timmy never 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?: Explain that they will need to hold Timmy in the prone position after the procedure.
5. Which action should the nurse implement?: Notify the cardiologist and do not allow Thomas
to sign the permit.
6. Which nursing intervention must be included in Timmy's plan of care related
to this diagnosis?: 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?: "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 the
nurse?: Certified Lactation Consultant (CLC).
9. Which measurement will be most useful to evaluate Timmy's response to
each feeding technique?: SaO2 changes during feeding.
10. Which intervention should the nurse implement prior to administering the
first dose of digoxin (Lanoxin) to Timmy?: Obtain Timmy's apical pulse to determine if it is within
the guidelines of the written prescription.
11. Which information should the nurse include when discussing this routine
laboratory test?: Instruct the parents to give a regular dose of medication at least 6 hours prior to the test.
12. The nurse further educates the parents about the digoxin medication and
instructs how to administer the medication. Which statement by the parents
demonstrates an understanding of the instructions?: I will give my child the medication at
the scheduled times.
13. Which intervention should the nurse implement first?: Attempt to stimulate Timmy's
breathing by rubbing the sole of his foot.
1/3
Study online at https://quizlet.com/_hntj6y
1. Which clinical manifestations would the nurse expect to assess in an infant
diagnosed with ventricular septal defect (VSD)?: Tachypnea and grunting with intercostal and
subcostal retractions.
2. The nurse understands that a child is experiencing heart failure when which
symptoms are found?: -Cool extremities.
-Peripheral edema.
-Nasal Flaring.
3. Which statement by Joan supports Timmy's diagnosis of CHF?: "Timmy never 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?: Explain that they will need to hold Timmy in the prone position after the procedure.
5. Which action should the nurse implement?: Notify the cardiologist and do not allow Thomas
to sign the permit.
6. Which nursing intervention must be included in Timmy's plan of care related
to this diagnosis?: 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?: "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 the
nurse?: Certified Lactation Consultant (CLC).
9. Which measurement will be most useful to evaluate Timmy's response to
each feeding technique?: SaO2 changes during feeding.
10. Which intervention should the nurse implement prior to administering the
first dose of digoxin (Lanoxin) to Timmy?: Obtain Timmy's apical pulse to determine if it is within
the guidelines of the written prescription.
11. Which information should the nurse include when discussing this routine
laboratory test?: Instruct the parents to give a regular dose of medication at least 6 hours prior to the test.
12. The nurse further educates the parents about the digoxin medication and
instructs how to administer the medication. Which statement by the parents
demonstrates an understanding of the instructions?: I will give my child the medication at
the scheduled times.
13. Which intervention should the nurse implement first?: Attempt to stimulate Timmy's
breathing by rubbing the sole of his foot.
1/3
