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 de- sired
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 t
enteral nutrition following surgery for gastric atresia.
1/
10
, 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.
2/
10
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 de- sired
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 t
enteral nutrition following surgery for gastric atresia.
1/
10
, 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.
2/
10
