PN Exit Hesi / Rationales
A client is found unresponsive. What should the PN do? - ANSWER-When a client is found unresponsive,
the PN should first obtain emergency help, a task that can be assigned to the UAP.
A client is in buck's skin traction, where should the PN assess for infection? - ANSWER-Insertion of a pin
into bone places the client at risk for infection of the bone and surrounding tissues. It is most important
for the PN to asses the area surrounding the skeletal pin insertion for signs of inflammation.
A client taking an SSRI presents with restlessness, tachycardia, fever, and elevated blood pressure. What
should the PN do first? - ANSWER-The PN should first contact the health care provider immediately and
hold all paroxetine doses until further prescriptions are provided.
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.
A living will - ANSWER-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.
A persistent dry cough is a side effect of what drug(s)? - ANSWER-A persistent dry cough is a side effect
of the antihypertensive agent quinapril, an angiotensin- Converting enzyme (ACE Inhibitor).
A postpartum client is shaking and states that she is cold. Which action should the PN take? - ANSWER-
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.
A postpartum clients fundus is elevated above the umbilicus. What action should the PN take? -
ANSWER-A fundus that is dextroverted (Up to the right) and elevated above the umbilicus is indicative
of bladder distension and urine retention. The PN should ensure that the client empties her bladder
before the post-partum exam.
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? - ANSWER-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.
Abnormal breathing patterns are - ANSWER-Dyspnea; tachypnea; bradypnea; hyperventilation; and
Cheyne-Stokes, Kussmaul, and Biot respirations.
Airway clearance - ANSWER-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.
An immunocompromised client is displaying multiple symptoms suggesting an infection is occurring.
What action should the PN take? - ANSWER-Since the client has other symptoms of an infection: Cough
, PN Exit Hesi / Rationales
and yellow tinged sputum. The priority action is to notify the charge nurse of the findings so that the
health care provider can be contacted and medical treatment can be initiated.
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.
AV fistula assessment - ANSWER-you should feel the thrill and hear the bruit, if not, this is an
emergency, notify the MD.
Thrill: Pulsation
Bruit: Audible stethoscope
Bone repair and callus formation - ANSWER-Callus formation is visualized on X- Ray and is a normal
stage of bone repair that indicates osteoblasts, blood vessels, and fibroblasts are surrounding the
fracture site and inflating cartilage synthesis, bone formation and healing. The PN should explain this
NORMAL HEALING PROCESS.
Buck's skin traction - ANSWER-Be sure the weights are hanging free. If the weights are resting on or
against any support, such as the foot of the bed or the floor, the purpose of the traction is defeated.
Cancer of the larynx risk factors - ANSWER-Men
Smoking
Chewing tabaco
Alcohol
Cardiovascular changes occur because - ANSWER-Alkalosis increases myocardial irritability, especially
when accompanied by hypokalemia.
Comfort measures - ANSWER-Comfort measures such as repositioning and a back rub, are the least
invasive and should be initiated before other interventions are implemented
Costochondritis - ANSWER-Inflammation of rib cartilage, The plan of care for someone who experiences
musculoskeletal pain is to administer analgesic (hydrocodone/acetaminophen/tramadol) and monitor
for shallow/ slow breathing.
Creatine kinase (CK) - ANSWER-Male: 55-170 U/L
Female: 30-135 U/L
Dehiscence - ANSWER-Dehiscence is a partial or complete separation of the outer wound layers,
sometimes described as a "splitting open of the wound."
Documentation of a urinary catheter - ANSWER-Record type and size of catheter inserted, amount of
fluid used to inflate the balloon, urine output and the quantity, color, and odor of the urine.
Evisceration - ANSWER-Evisceration is the complete separation of a wound with protrusion of the
viscera, which usually occurs 7-10 days Post Operative.
A client is found unresponsive. What should the PN do? - ANSWER-When a client is found unresponsive,
the PN should first obtain emergency help, a task that can be assigned to the UAP.
A client is in buck's skin traction, where should the PN assess for infection? - ANSWER-Insertion of a pin
into bone places the client at risk for infection of the bone and surrounding tissues. It is most important
for the PN to asses the area surrounding the skeletal pin insertion for signs of inflammation.
A client taking an SSRI presents with restlessness, tachycardia, fever, and elevated blood pressure. What
should the PN do first? - ANSWER-The PN should first contact the health care provider immediately and
hold all paroxetine doses until further prescriptions are provided.
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.
A living will - ANSWER-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.
A persistent dry cough is a side effect of what drug(s)? - ANSWER-A persistent dry cough is a side effect
of the antihypertensive agent quinapril, an angiotensin- Converting enzyme (ACE Inhibitor).
A postpartum client is shaking and states that she is cold. Which action should the PN take? - ANSWER-
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.
A postpartum clients fundus is elevated above the umbilicus. What action should the PN take? -
ANSWER-A fundus that is dextroverted (Up to the right) and elevated above the umbilicus is indicative
of bladder distension and urine retention. The PN should ensure that the client empties her bladder
before the post-partum exam.
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? - ANSWER-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.
Abnormal breathing patterns are - ANSWER-Dyspnea; tachypnea; bradypnea; hyperventilation; and
Cheyne-Stokes, Kussmaul, and Biot respirations.
Airway clearance - ANSWER-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.
An immunocompromised client is displaying multiple symptoms suggesting an infection is occurring.
What action should the PN take? - ANSWER-Since the client has other symptoms of an infection: Cough
, PN Exit Hesi / Rationales
and yellow tinged sputum. The priority action is to notify the charge nurse of the findings so that the
health care provider can be contacted and medical treatment can be initiated.
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.
AV fistula assessment - ANSWER-you should feel the thrill and hear the bruit, if not, this is an
emergency, notify the MD.
Thrill: Pulsation
Bruit: Audible stethoscope
Bone repair and callus formation - ANSWER-Callus formation is visualized on X- Ray and is a normal
stage of bone repair that indicates osteoblasts, blood vessels, and fibroblasts are surrounding the
fracture site and inflating cartilage synthesis, bone formation and healing. The PN should explain this
NORMAL HEALING PROCESS.
Buck's skin traction - ANSWER-Be sure the weights are hanging free. If the weights are resting on or
against any support, such as the foot of the bed or the floor, the purpose of the traction is defeated.
Cancer of the larynx risk factors - ANSWER-Men
Smoking
Chewing tabaco
Alcohol
Cardiovascular changes occur because - ANSWER-Alkalosis increases myocardial irritability, especially
when accompanied by hypokalemia.
Comfort measures - ANSWER-Comfort measures such as repositioning and a back rub, are the least
invasive and should be initiated before other interventions are implemented
Costochondritis - ANSWER-Inflammation of rib cartilage, The plan of care for someone who experiences
musculoskeletal pain is to administer analgesic (hydrocodone/acetaminophen/tramadol) and monitor
for shallow/ slow breathing.
Creatine kinase (CK) - ANSWER-Male: 55-170 U/L
Female: 30-135 U/L
Dehiscence - ANSWER-Dehiscence is a partial or complete separation of the outer wound layers,
sometimes described as a "splitting open of the wound."
Documentation of a urinary catheter - ANSWER-Record type and size of catheter inserted, amount of
fluid used to inflate the balloon, urine output and the quantity, color, and odor of the urine.
Evisceration - ANSWER-Evisceration is the complete separation of a wound with protrusion of the
viscera, which usually occurs 7-10 days Post Operative.
