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HESI RN EXIT CASE STUDY: CONGENITAL HEART DISEASE
1. 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
2. The nurse understands that a child is experiencing heart failure when which symptoms are found
ANS: -Cool extremities. -Peripheral edema. -Nasal Flaring.
3. 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."
4. 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.
5. Which action should the nurse implement
ANS: 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
ANS: 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
ANS: "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
ANS: Certified Lactation Consultant (CLC).
9. Which measurement will be most useful to evaluate Timmy's response to each feeding technique
ANS: SaO2 changes during feeding.
10. Which intervention should the nurse implement prior to administering the first dose of digoxin
(Lanoxin) to Timmy ANS: 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
ANS: 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 ANS: I will give my child the medication at the scheduled times.
13. Which intervention should the nurse implement first
ANS: Attempt to stimulate Timmy's breathing by rubbing the sole of his foot.
14. Which intervention should the nurse implement first
ANS: Administer oxygen to Timmy and stay with him.
15. Which data supports the nurse's response
ANS: Timmy plays with his feet and puts them in his mouth.
26. How should the nurse respond to this situation
ANS: Discuss Thomas and Joan attending a support group for parents of children with congenital heart problems.
27. Which preoperative intervention has priority at this time
ANS: Offer verbal and written information about Timmy's surgery.
28. What is the best response by the nurse
ANS: "It is a machine that takes over the roles of the lungs and heart during Timmy's surgery."
29. Which additional assessment data warrants immediate intervention by the nurse
ANS: -Apical pulse rate of 88/minute. -Hemoglobin 7 g/dL. -Serum potassium level 2.6 mEq/l.
30. Which intervention is important to include in Timmy's plan of care to ad- dress this concern in the
immediate postoperative period ANS: Monitor the infant's glucose level.
31. Which intervention should the nurse implement to address their concern about Timmy's
postoperative pain ANS: Explain that a continuous IV infusion of pain medication is being given to Timmy and will provide a consistent level of pain relief.
32. Which statement by Joan indicates that the teaching has been effective?-
: "We must resume Timmy's regular meal, sleep, and play times as soon as we get home."
33. Which statement by Joan indicates that the teaching has been effective?-
: -"We must resume Timmy's regular meal, sleep, and play times as soon as we get home." -"Pat the incision dry, but do not rub it until it is completely healed."
