PN HESI EXIT VERSION 5 NEWEST 2024 ACTUAL EXAM
COMPLETE 160 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |
ALREADY GRADED A+
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.
Where can hospice care be provided? - ANSWER: Hospice care can be provided
anywhere the client lives, including in the home, and focuses on comfort, dignity and
emotional support.
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.
Presbycusis in older clients - ANSWER: 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? -
ANSWER: 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 - 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.
COMPLETE 160 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |
ALREADY GRADED A+
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.
Where can hospice care be provided? - ANSWER: Hospice care can be provided
anywhere the client lives, including in the home, and focuses on comfort, dignity and
emotional support.
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.
Presbycusis in older clients - ANSWER: 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? -
ANSWER: 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 - 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.
