PN Exit Hesi Rationales Exam with Complete Solutions

PN Exit Hesi Rationales Exam with Complete Solutions A fully oriented person is ANSWER 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 ANSWER 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) ANSWER 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 ANSWER 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 ANSWER 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 ANSWER 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.