PN EXIT HESI / RATIONALES QUESTIONS AND ANSWERS 2026/2027
LATEST UPDATE
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.
Presbycusis in older clients
Hearing loss.
The PN should determine if the client's hearing problem is new or gradual chronic condition.
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.
A pregnant client reports contractions that are 7-15 minutes apart, lasting 20-30 seconds
with mild intensity. What should the PN instruct her to do?
The contractions of true labor generally begin in the back and radiate to the front of the
abdomen, and become increasingly regular, stronger and longer-lasting. The client is not yet in
active labor and would probably be more comfortable at home until she is in labor.
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 postpartum client is shaking and states that she is cold. Which action should the PN
take?
Maternal Vasomotor instability after delivery is usually manifested by uncomfortable shaking
and reports of being cold. The PN should apply warmed blankets to provide external warmth.
What interventions should be used for a newborn with signs of hypoglycemia?
LATEST UPDATE
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.
Presbycusis in older clients
Hearing loss.
The PN should determine if the client's hearing problem is new or gradual chronic condition.
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.
A pregnant client reports contractions that are 7-15 minutes apart, lasting 20-30 seconds
with mild intensity. What should the PN instruct her to do?
The contractions of true labor generally begin in the back and radiate to the front of the
abdomen, and become increasingly regular, stronger and longer-lasting. The client is not yet in
active labor and would probably be more comfortable at home until she is in labor.
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 postpartum client is shaking and states that she is cold. Which action should the PN
take?
Maternal Vasomotor instability after delivery is usually manifested by uncomfortable shaking
and reports of being cold. The PN should apply warmed blankets to provide external warmth.
What interventions should be used for a newborn with signs of hypoglycemia?
