ESTUDYR
NCLEX-Style Case Study: Congenital Heart
Disease (Tetralogy of Fallot)
Client Scenario (Applies to all items)
The nurse in the pediatric emergency department cares for a 2-year-old male client.
Health History, Assessment, and Vital Signs:
A 2-year-old child presents with his mother, who reports episodes where the child suddenly
becomes cyanotic, short of breath, and irritable, especially during crying or feeding. The
mother states that during these episodes, the child often squats or draws his knees to his
chest.
On assessment, the child appears cyanotic around the lips (central cyanosis) and has
clubbing of the fingers. A harsh systolic murmur is auscultated.
Vital signs on arrival:
Temperature: 37.0°C (98.6°F)
Heart rate: 140/min
Respiratory rate: 34/min
Blood pressure: 92/58 mmHg
Oxygen saturation: 82% on room air
Item 1 of 6
Question:
Click to select the findings that require immediate follow-up by the nurse.
(Select all that apply)
Oxygen saturation 82%
Central cyanosis
Knee-chest positioning
Harsh systolic murmur
Clubbing of fingers
Heart rate 140/min
, ESTUDYR
Correct Answers:
Oxygen saturation 82%
Central cyanosis
Knee-chest positioning
Rationale:
These findings indicate a cyanotic episode (Tet spell), which is a medical emergency
requiring immediate intervention to improve oxygenation.
The murmur and clubbing are chronic findings associated with congenital heart disease and
are not the most urgent compared to acute hypoxia.
Item 2 of 6
Question:
For each finding, indicate whether it is most consistent with acyanotic heart disease,
cyanotic heart disease, or respiratory disorder.
Finding Acyanotic CHD Cyanotic CHD Respiratory Disorder
Central cyanosis ☐ ☐ ☐
Clubbing of fingers ☐ ☐ ☐
Harsh systolic murmur ☐ ☐ ☐
Low oxygen saturation ☐ ☐ ☐
Tachypnea ☐ ☐ ☐
Correct Answers:
Central cyanosis → Cyanotic CHD
Clubbing of fingers → Cyanotic CHD
Harsh systolic murmur → Cyanotic CHD
Low oxygen saturation → Cyanotic CHD, Respiratory disorder
Tachypnea → All three
Rationale:
Tetralogy of Fallot is a cyanotic congenital heart defect characterized by decreased
oxygenation due to right-to-left shunting.
Clubbing and chronic cyanosis are hallmark signs. Tachypnea can occur in both cardiac and
respiratory conditions.
NCLEX-Style Case Study: Congenital Heart
Disease (Tetralogy of Fallot)
Client Scenario (Applies to all items)
The nurse in the pediatric emergency department cares for a 2-year-old male client.
Health History, Assessment, and Vital Signs:
A 2-year-old child presents with his mother, who reports episodes where the child suddenly
becomes cyanotic, short of breath, and irritable, especially during crying or feeding. The
mother states that during these episodes, the child often squats or draws his knees to his
chest.
On assessment, the child appears cyanotic around the lips (central cyanosis) and has
clubbing of the fingers. A harsh systolic murmur is auscultated.
Vital signs on arrival:
Temperature: 37.0°C (98.6°F)
Heart rate: 140/min
Respiratory rate: 34/min
Blood pressure: 92/58 mmHg
Oxygen saturation: 82% on room air
Item 1 of 6
Question:
Click to select the findings that require immediate follow-up by the nurse.
(Select all that apply)
Oxygen saturation 82%
Central cyanosis
Knee-chest positioning
Harsh systolic murmur
Clubbing of fingers
Heart rate 140/min
, ESTUDYR
Correct Answers:
Oxygen saturation 82%
Central cyanosis
Knee-chest positioning
Rationale:
These findings indicate a cyanotic episode (Tet spell), which is a medical emergency
requiring immediate intervention to improve oxygenation.
The murmur and clubbing are chronic findings associated with congenital heart disease and
are not the most urgent compared to acute hypoxia.
Item 2 of 6
Question:
For each finding, indicate whether it is most consistent with acyanotic heart disease,
cyanotic heart disease, or respiratory disorder.
Finding Acyanotic CHD Cyanotic CHD Respiratory Disorder
Central cyanosis ☐ ☐ ☐
Clubbing of fingers ☐ ☐ ☐
Harsh systolic murmur ☐ ☐ ☐
Low oxygen saturation ☐ ☐ ☐
Tachypnea ☐ ☐ ☐
Correct Answers:
Central cyanosis → Cyanotic CHD
Clubbing of fingers → Cyanotic CHD
Harsh systolic murmur → Cyanotic CHD
Low oxygen saturation → Cyanotic CHD, Respiratory disorder
Tachypnea → All three
Rationale:
Tetralogy of Fallot is a cyanotic congenital heart defect characterized by decreased
oxygenation due to right-to-left shunting.
Clubbing and chronic cyanosis are hallmark signs. Tachypnea can occur in both cardiac and
respiratory conditions.
