Author Question: A nurse notes that a child's chart describes a heave. Which assessment should the nurse perform to ... (Read 70 times)

jman1234 · **on:** Jun 28, 2018

A nurse notes that a child's chart describes a heave. Which assessment should the nurse perform to correlate with this finding?

A.
Assess for nausea.
B.
Auscultate for heart sounds.
C.
Listen to lung sounds.
D.
Review the last ECG

Question 2

A child has had a closure device inserted in interventional radiology for an atrial septal defect (ASD). Two hours later the child is pale, tachycardic, and hypotensive. Which action by the nurse takes priority?

A.
Administer a beta blocker to slow the heart rate down.
B.
Document findings then notify the health-care provider.
C.
Increase the rate of the IV fluid administration.
D.
Prepare the child to return to interventional radiology.

InfiniteSteez · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
A heave is an abnormal tremor that accompanies a vascular or cardiac murmur, so the nurse would listen to heart sounds. Lung sounds and ECGs are not directly related to a heave. Nausea is not related at all.

Answer to Question 2

ANS: D
Complications from insertion of closure devices include bleeding, cardiac tamponade, or migration of the device. The provider needs to be notified stat, and the child prepared to return to the interventional radiology suite. A beta blocker is inappropriate in this setting. The nurse should notify the provider and obtain orders prior to changing IV fluid rates. Documentation needs to be thorough, but should wait until after the provider is notified.