PN Exit HESI Exam Questions with
Rationales
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.
How do you prevent tissue loss in a client with hyperemia? - Answer-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 - Answer-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 - Answer-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? - Answer-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 - Answer-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 - Answer-Sitting upright facilities diaphragm excursion and enhances thoracic and
abdominal expansion.
What outdoor game provides socialization for older clients? - Answer-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.
Rationales
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.
How do you prevent tissue loss in a client with hyperemia? - Answer-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 - Answer-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 - Answer-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? - Answer-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 - Answer-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 - Answer-Sitting upright facilities diaphragm excursion and enhances thoracic and
abdominal expansion.
What outdoor game provides socialization for older clients? - Answer-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.
