The nurse is conducting a staff in-service on congenital heart ...

[rlane42]

The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?
 
  a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
  b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
  c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
  d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

Question 2

The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is too wet. The nurse finds the bandage and bed soaked with blood.
 
  The most appropriate initial nursing action is to:
  a. notify physician.
  b. apply new bandage with more pressure.
  c. place the child in Trendelenburg position.
  d. apply direct pressure above catheterization site.

[Cheesycrackers]

Answer to Question 1

ANS: A
Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.

Answer to Question 2

ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.