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1. Which clinical manifestations would the nurse expect to assess in an infant diagnosed with a ventricular septal defect?

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Tachypnea and grunting with intercostal and subcostal retraction

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2. Which statement by Teresa supports Billy's diagnosis of CHF?

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"Billy never seems to get full when I breastfeed him for a long time."

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3. What should the nurse include when teaching Billy's parents about post-procedure care?

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Explain that they will need to hold Billy in the prone position after the procedure

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4. As the nurse is obtaining informed consent for Billy's cardiac catheterization, Aaron says, "I am still not exactly sure why the doctor has to do the test." Which action should the nurse implement?

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Notify the cardiologist and do not allow Aaron to sign the permit

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5. Which nursing intervention must be included in Billy's plan of care related to this diagnosis?

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Assess the infant's peripheral pulses and capillary refill time

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6. Which nursing diagnosis is important to include in the plan of care?

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Imbalanced nutrition: less than body requirements

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7. Aaron asks, "Why do we need to use a soft nipple with a large hole to feed Billy?" What is the best response by the nurse?

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

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8. Which member of the perinatal care team will best be able to assist the nurse?

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Certified Lactation Consultant (CLC)

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9. Which measurement will be most useful to evaluate Billy's response to each feeding technique?

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SaO2 changes during feeding

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10. Which intervention should the nurse implement prior to administering the first dose of digoxin (Lanoxin) to Billy?

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Obtain Billy's apical pulse to determine if it is within the guidelines of the written order

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11. Which information should the nurse include when discussing this routine laboratory test?

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Instruct the parents to give a regular dose of medication at least 6 hours prior to the test

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12. Which intervention should the nurse implement first?

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Attempt to stimulate Billy's breathing by rubbing the sole of his foot

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13. Billy is responsive but lethargic and very irritable. Billy's pulse oximeter reading is 90%. Which intervention should the nurse implement first?

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Administer oxygen to Billy and stay with him

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14. Teresa asks the nurse, "Is Billy growing all right?" The nurse responds that Billy seems to be right on target for a 4-month-old. Which data supports the nurse's response?

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Billy plays with his feet and puts them in his mouth

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15. Which activity should the nurse include when discussing activities appropriate for a 4-month-old's growth and development?

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Read brightly colored book to Billy

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16. According to Erikson, which state is normal for an infant this age?

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Trust vs. Mistrust

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17. The nurse walks into Billy's room to complete the shift assessment and finds him sleeping soundly in his crib and Teresa crying quietly and staring out the window. Which action by the nurse is the most therapeutic?

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Stand by Teresa and say, "I can see you are upset. Would you like to talk?"

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18. Teresa asks the nurse, "Why did this happen to my baby? What did I do wrong? I should not have continued to work up until the day he was born." What is the best response by the nurse?

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"It is not known what causes an infant to be born with a VSD, but a working mother is not a risk factor."

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19. How should the nurse respond when addressing this alternative (herbs) therapy?

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"You should consult with Billy's doctor before allowing him to get any of the herbs."

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20. Teresa and Aaron's priest arrives asking "How is Billy Adams doing, and what is his room number?" How should the nurse respond?

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"Billy's room number is 410. I think Mr. Adams is in the room. I'll be happy to walk you down there with you."

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21. Which of Billy's nursing tasks would be appropriate to delegate to an unlicensed assistive personnel (UAP)?

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Sit with Billy while Teresa takes a shower.

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22. Which prescription for care should the nurse question as a transcription error on the plan of care?

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Administer digoxin 12.5mg IVP twice a day

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23. Which statements by Aaron indicates that the CPR teaching has been effective? (Select all)

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-I will perform 30 chest compressions to 2 breaths, at a rate of 100 compressions per minute -I will perform chest compressions prior to rescue breathing

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24. Which intervention should the nurse include when teaching the parents about the administration of digoxin?

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Advise the parents to administer the medication about 20-30 minutes before the infant is fed.

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25. Teresa plans to quit work to care for Billy. How should the nurse respond?

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Discuss Aaron and Teresa attending a support group for parents of children with congenital heart problems

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26. Which preoperative intervention has priority at this time?

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Offer verbal and written information about Billy's surgery

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27. Teresa states, "I am not sure I understand what the cardiopulmonary bypass machine does." What is the best response by the nurse?

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"It is a machine that takes over the roles of the lungs and heart during Billy's surgery."

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28. Which additional assessment data warrants immediate intervention by the nurse? (Select all)

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-Apical pulse rate of 88/min -Serum potassium level 2.6 mEq/l

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29. Which laboratory result requires immediate intervention by the nurse?

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Hemoglobin 8 g/dl

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30. Which intervention is important to include in Billy's plan of care to address this concern in the immediate postoperative period?

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Monitor the infant's glucose level

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31. Which intervention should the nurse implement to address their concern about Billy's postoperative pain?

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Explain that a continuous IV infusion of pain medication is being given to Billy and will provide a consistent level of pain relief

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32. Which information should be included when teaching Billy's parents prior to discharge?

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Pat the incision dry, but do not rub it until it is completely healed

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33. Which statement by Teresa indicates that the teaching has been effective?

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"We must resume Billy's regular meal, sleep, and play times as soon as we get home."

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HESI Case Studies–Pediatrics-Congenital Heart Disease (Billy Adams) – Flashcards

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