PN Exit Hesi / Rationales 2024
A fully oriented person is - Oriented to person, place, time, & situation (oriented x4).
A person who is only oriented to one of these elements is at risk for injury. The PN
should provide instructions to the UAP about additional support to the client.
Orthostatic falls - The PN should obtain standing blood pressure measurements to
evaluate the orthostatic falls in the blood pressure that can cause lightheaded or faint
feeling when rising from a lying position.
Atopic dermatitis (Eczema) - Heat and humidity can cause perspiration, which
intensifies itching with atopic dermatitis (Eczema), so a client should be encouraged to
shower, using non perfume scented soaps.
Rotating injection sites - The PN should reteach the client to rotate the noon site to a
site other than the same one used for the AM dose.. Rotation is recommended for the
dose used during the one specific time of the day.
Pain scale - A rating scale should be used by the client to evaluate current pain. The
PN should also determine when the last pain medication was administered and the
effectiveness of that last dose.
Nystatin administration to an infant - Nystatin is the most commonly used antifungal
agent for oral candidiasis. When administering nystatin to an infant, the medication
needs to be applied topically by using a gloved finger to rub the suspension over the
infected area.
How do you prevent tissue loss in a client with hyperemia? - The presence of
reactive hyperemia occurs from pressure causing dilation of superficial capillaries, and
resolves without tissue loss if the pressure if relieved. The UAP should be instructed in
the need to turn the client every 2 hours.
PNs role during a fire alarm - The PN has the expertise to determine how to safely
transport and evacuate residents with varying medical problems during a fire alarm.
Intention of droplet precaution - Droplet precautions are intended to prevent
transmission of pathogens spread through close respiratory or mucous membrane
contact with respiratory secretions and include keeping the door to the client's room
closed.
How should the PN respond to an RN who requested the PN to administer
unlabeled medication that the PN did not draw? - The PN can respond in an
assertive manner by refusing to administer the medication but offering to assist the RN
, with another task. An aggressive response is refusing to administer the drug while not
offering to help in another way.
Slight bleeding during stoma care - While providing stoma care with a client, it is a
normal occurrence to see a little blood on a washcloth due to the stoma being a very
vascular site.
Upright positioning - Sitting upright facilities diaphragm excursion and enhances
thoracic and abdominal expansion.
What outdoor game provides socialization for older clients? - An outdoor team
game of ring-toss provides opportunities for socialization, as well as exercise. The
activity addresses the older clients' psychosocial, interpersonal and physical needs.
Where is the center of gravity in an elderly client? - The center of gravity changes
as a person age from the hips to the UPPER TORSO.
Where can hospice care be provided? - Hospice care can be provided anywhere the
client lives, including in the home, and focuses on comfort, dignity and emotional
support.
A living will - Describes the clients desires regarding end-of life care, but does not
provide specifics regarding hospice care. Under hospice care, medications are used for
symptom control but also for routine medical management or treatment of medical
problems. The client should plan to make decisions, in collaboration with family
members as desired by the client.
How should the PN approach a elderly client adjusting the a new nursing facility?
- Relocation often results in confusion among elderly clients during times of adjustment
to new surroundings. The PN should remind the client which day it is when she forgets
or becomes confused.
Airway clearance - Airway clearance is the highest priority nursing intervention, and
further resuscitative efforts are effective only when the airway is patent. Suctioning
clears passages and prevents mucus or feedings from obstructing the airway during
resuscitation.
The fetal heart rate is 180, what action should the PN take? - Although a fetal heart
rate of 180 (Normal Range is 110-160) may be an acceleration secondary to fetal
movement, this finding should be reported immediately to the RN it indicates
tachycardia which requires further assessment.
Which food options would you offer a vegetarian client in need of foods high in
iron? - The client should be encouraged to increase her intake of green leafy
vegetables such as Spinach, Broccoli, Kale and other vegetarian sources of iron, such
as oatmeal, lentils and black beans.
A fully oriented person is - Oriented to person, place, time, & situation (oriented x4).
A person who is only oriented to one of these elements is at risk for injury. The PN
should provide instructions to the UAP about additional support to the client.
Orthostatic falls - The PN should obtain standing blood pressure measurements to
evaluate the orthostatic falls in the blood pressure that can cause lightheaded or faint
feeling when rising from a lying position.
Atopic dermatitis (Eczema) - Heat and humidity can cause perspiration, which
intensifies itching with atopic dermatitis (Eczema), so a client should be encouraged to
shower, using non perfume scented soaps.
Rotating injection sites - The PN should reteach the client to rotate the noon site to a
site other than the same one used for the AM dose.. Rotation is recommended for the
dose used during the one specific time of the day.
Pain scale - A rating scale should be used by the client to evaluate current pain. The
PN should also determine when the last pain medication was administered and the
effectiveness of that last dose.
Nystatin administration to an infant - Nystatin is the most commonly used antifungal
agent for oral candidiasis. When administering nystatin to an infant, the medication
needs to be applied topically by using a gloved finger to rub the suspension over the
infected area.
How do you prevent tissue loss in a client with hyperemia? - The presence of
reactive hyperemia occurs from pressure causing dilation of superficial capillaries, and
resolves without tissue loss if the pressure if relieved. The UAP should be instructed in
the need to turn the client every 2 hours.
PNs role during a fire alarm - The PN has the expertise to determine how to safely
transport and evacuate residents with varying medical problems during a fire alarm.
Intention of droplet precaution - Droplet precautions are intended to prevent
transmission of pathogens spread through close respiratory or mucous membrane
contact with respiratory secretions and include keeping the door to the client's room
closed.
How should the PN respond to an RN who requested the PN to administer
unlabeled medication that the PN did not draw? - The PN can respond in an
assertive manner by refusing to administer the medication but offering to assist the RN
, with another task. An aggressive response is refusing to administer the drug while not
offering to help in another way.
Slight bleeding during stoma care - While providing stoma care with a client, it is a
normal occurrence to see a little blood on a washcloth due to the stoma being a very
vascular site.
Upright positioning - Sitting upright facilities diaphragm excursion and enhances
thoracic and abdominal expansion.
What outdoor game provides socialization for older clients? - An outdoor team
game of ring-toss provides opportunities for socialization, as well as exercise. The
activity addresses the older clients' psychosocial, interpersonal and physical needs.
Where is the center of gravity in an elderly client? - The center of gravity changes
as a person age from the hips to the UPPER TORSO.
Where can hospice care be provided? - Hospice care can be provided anywhere the
client lives, including in the home, and focuses on comfort, dignity and emotional
support.
A living will - Describes the clients desires regarding end-of life care, but does not
provide specifics regarding hospice care. Under hospice care, medications are used for
symptom control but also for routine medical management or treatment of medical
problems. The client should plan to make decisions, in collaboration with family
members as desired by the client.
How should the PN approach a elderly client adjusting the a new nursing facility?
- Relocation often results in confusion among elderly clients during times of adjustment
to new surroundings. The PN should remind the client which day it is when she forgets
or becomes confused.
Airway clearance - Airway clearance is the highest priority nursing intervention, and
further resuscitative efforts are effective only when the airway is patent. Suctioning
clears passages and prevents mucus or feedings from obstructing the airway during
resuscitation.
The fetal heart rate is 180, what action should the PN take? - Although a fetal heart
rate of 180 (Normal Range is 110-160) may be an acceleration secondary to fetal
movement, this finding should be reported immediately to the RN it indicates
tachycardia which requires further assessment.
Which food options would you offer a vegetarian client in need of foods high in
iron? - The client should be encouraged to increase her intake of green leafy
vegetables such as Spinach, Broccoli, Kale and other vegetarian sources of iron, such
as oatmeal, lentils and black beans.
