Rationals - Exit HESI PN V2

1. rationale: The PN should observe the UAP's ability to safely feed a client at risk for aspiration. Once the UP's ability to safely perform the skill has been established, the UAP should identify and report if a client develops a compromised airway. 2. rationale: Behavioral modification programs are most successful when the desired behavior is rewarded with a client-specific preference. The practical nurse (PN) should provide a positive reinforcement that will motivate the client. 3. rationale: Chronic kidney disease (CKD) is a progressive, irreversible loss of kidney function, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated blood pressure, and changes in mental status. In the plan of care, weigh every morning should be implemented by the PN to evaluate fluid retention and overload that can affect cardiac workload 4. rationale: The PN should interpret a loud, harsh murmur upon auscultation with a palpable systolic thrill as a normal finding for a 9-month-old with VSD. A VSD is an abnormal opening between the right and left ventricle. The harsh murmur and thrill is produced by the vibrations in the heart caused by the back and flow of blood 5. rationale: The PN should interpret a loud, harsh murmur upon auscultation with a palpable systolic thrill as a normal finding for a 9-month-old with VSD. A VSD is an abnormal opening between the right and left ventricle. The harsh murmur and thrill is produced by the vibrations in the heart caused by the back and flow of blood. 6. rationale: Zinc, a trace element and component of total parenteral nutrition, can be an overlooked supplement when converting to enteral feeds. The practical nurse (PN) should identify a low serum zinc level as an indicator of failure to thrive in an infant transitioning to enteral nutrition following surgery for gastric atresia. 7. rationale: The amniotic sac protects the fetus from potential infections, and rupture or leakage of the amniotic sac at 39-weeks gestation can be confused with urination. The presence of dribbling urine should be further assessed. 8. rationale: When the vial label is scanned (4 mg/2mL), a dosage pop-up appears as a prompt to enter the correct administration dosage. Using the formula, D/H x A (3 mg/4mg x 2) to calculate the administration dosage, the entry in the MAR should reflect 3 mg/1.5 mL as the prepared dose for administration. 9. rationale: Acarbose is an alpha-glucoside inhibitor that delays absorption of dietary carbohydrates and thereby reduces the increase in blood glucose level after a meal. The medication should be taken with the first bite of a meal, so the practical nurse (PN) should hold the medication until the meal tray arrives on the unit. 10. rationale: For an older client who is 12 hours post-op, pain can be exhibited as confusion. To ensure the client's safety, the practical nurse (PN) should delegate every 15 minutes monitoring of the client to the unlicensed assistive personnel (UP). The UP needs to notify the PN of changes in the client's condition and keep the upper side rails up until the client is resting comfortably 11. rationale: If a client has a history of tuberculosis, the practical nurse (PN) should review the electronic medical record for the administration of rifampin. Rifampin can decrease the effectveness of warfarin. 12. rationale: A client with bulimia nervosa (BN) has recurrent episodes of binge eating, usually followed by purging. The practical nurse (PN) should recognize that imbalanced nutrition potentially impacts the development of other physiological problems such as a risk for imbalanced fluid volume and decreased cardiac output. 13. rationale: Talking directly to the adolescent who is in a sustained vegetative state provides environmental stimulation and includes him in an interpersonal re- lationship because he may still be able to hear and process verbal communication 14. rationale: The poetical phase occurs after a seizure and is a time when the client often feels drowsy and appears somewhat disoriented. Vital signs should be measured to ensure client stability and then the client should be allowed to rest in a safe environment. The postictal phase is not an effective time for patient teaching, and an aura does not occur during this phase 15. rationale: Those with dementia often experience disorientation when the sun goes down, thus the term "sundowning," and become confused by multiple sources of stimuli. The use of a soothing sound generator or white noise helps create an environment that blocks distracting and confusing sounds. 16. rationale: Obsessive thoughts are obsessive preoccupation that the client is unable to control and interferes with the client's activities of daily living. 17. rationale: According to the US Occupational Safety and Health Administration (OSHA), contaminated wastes should be disposed in red bags or red containers. They can also be placed in an orange-red or fluorescent orange container with a bio-hazard symbo