The nurse is planning care for an 8-month-old infant with a ...

[segrsyd]

The nurse is planning care for an 8-month-old infant with a ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this patient?
 
  A) Impaired gas exchange related to a right-to-left shunt
  B) Impaired skin integrity related to poor peripheral circulation
  C) Ineffective airway clearance related to altered pulmonary status
  D) Ineffective tissue perfusion related to inefficiency of the heart as a pump

Question 2

The parents of a child having a cardiac catheterization are waiting to see the child after the procedure. What should the nurse instruct the parents to expect when seeing the child for the first time?
 
  A) The child will be sleeping for at least 8 hours.
  B) A bulky pressure dressing will be present over the insertion site.
  C) The child will have bruising over the upper and lower extremities.
  D) The child will be on seizure precautions and have padded side rails.

[kthug]

Answer to Question 1

D
Feedback:
Ventricular septal defect is the most common type of congenital cardiac disorder. With this disorder, an opening is present in the septum between the two ventricles. Blood shunts from left to right across the septum impairing the efficiency of the heart because blood that should be forced into the aorta and out to the body from contraction of the left ventricle shunts back into the pulmonary circulation, resulting in right ventricular hypertrophy and increased pressure in the pulmonary artery. This disorder does not impair gas exchange, cause impaired skin integrity, or cause ineffective airway clearance.

Answer to Question 2

B
Feedback:
When a child returns from a cardiac catheterization, a pressure dressing will be present over the catheter insertion site. This dressing is snug and will be checked to ensure that no bleeding is occurring. The child may or may not be sleepy after the procedure. The child will not have bruising over the upper and lower extremities. Seizure precautions are not necessary after a cardiac catheterization.