RN HESI Exit Exam Capstone

Correct Answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

Correct Answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

Correct Answer: B

Rationale: A decrease in white blood cell count indicates that the infection is responding to treatment and the client's condition is improving. Monitoring the white blood cell count is a more objective indicator of the body's response to the antibiotics. Choices A, C, and D may also be positive signs, but they are less specific and may vary among individuals. Respiratory rate alone may not be sufficient to indicate improvement, as other factors can influence it. Energy levels and cough characteristics are subjective and may not always correlate with the effectiveness of antibiotic treatment.

Correct Answer: B

Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.

Correct Answer: D

Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.