HESI RN Exit Exam Capstone

Correct Answer: A

Rationale: Monitoring respiratory rate helps assess for respiratory depression, a common side effect of morphine.

Correct Answer: B

Rationale: A neurological assessment is the priority when a stroke is suspected to determine the extent of brain injury and identify any immediate risks, such as impaired airway, speech deficits, or loss of motor function. Early recognition of these signs is essential for timely intervention and to guide further treatment like the administration of tPA, if appropriate.

Correct Answer: D

Rationale: Intravenous fluids are essential for rehydrating an infant who is likely suffering from dehydration due to projectile vomiting. This condition, commonly related to pyloric stenosis, causes rapid fluid loss. Oral rehydration methods might not be sufficient or appropriate for such a young infant, especially if vomiting persists. IV therapy ensures controlled and adequate fluid replacement to stabilize the child.

Correct Answer: A

Rationale: Elevating the affected leg helps reduce swelling and improve venous return, which is important for preventing complications in clients with DVT. Other interventions, such as ambulation, are secondary to leg elevation.

Correct Answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring.