PN EXIT HESI /RATIONALES
2025/2026 EXAMINATION
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.
Where is the center of gravity in an elderly client? - ANSWER-The
center of gravity changes as a person age from the hips to the UPPER
TORSO.
2025/2026 EXAMINATION
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.
Where is the center of gravity in an elderly client? - ANSWER-The
center of gravity changes as a person age from the hips to the UPPER
TORSO.
