PN Exit Hesi / Rationales
A fully oriented person is correct answersOriented 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 correct answersThe 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) correct answersHeat 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 correct answersThe 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 correct answersA 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 correct answersNystatin 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? correct answersThe 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 correct answersThe 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 correct answersDroplet 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? correct answersThe 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 correct answersWhile 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 correct answersSitting upright facilities diaphragm excursion and enhances thoracic and abdominal expansion.
What outdoor game provides socialization for older clients? correct answersAn 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? correct answersThe center of gravity changes as a person age from the hips to the UPPER TORSO.
Where can hospice care be provided? correct answersHospice care can be provided anywhere the client lives, including in the home, and focuses on comfort, dignity and emotional support.
A living will correct answersDescribes 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 correct answersHearing loss.
A fully oriented person is correct answersOriented 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 correct answersThe 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) correct answersHeat 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 correct answersThe 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 correct answersA 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 correct answersNystatin 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? correct answersThe 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 correct answersThe 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 correct answersDroplet 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? correct answersThe 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 correct answersWhile 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 correct answersSitting upright facilities diaphragm excursion and enhances thoracic and abdominal expansion.
What outdoor game provides socialization for older clients? correct answersAn 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? correct answersThe center of gravity changes as a person age from the hips to the UPPER TORSO.
Where can hospice care be provided? correct answersHospice care can be provided anywhere the client lives, including in the home, and focuses on comfort, dignity and emotional support.
A living will correct answersDescribes 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 correct answersHearing loss.
