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PN EXIT HESI OR RATIONALES LATEST FINAL EXAM UPDATED FOR
2025 - 2026 TOP SCORE COMPREHENSIVE QUESTIONS WITH 100%
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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.
For a newborn who is exhibiting signs of hypoglycemia (Normal Glucose 70-110 mg/Dl or less than 6.1mmol/l or SI units) which is common in infants born to mothers with gestational diabetes, early and prompt feeding should begin to alleviate hypoglycemia. A postpartum clients fundus is elevated above the umbilicus. What action should the PN take? 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. What should the PN monitor in a pregnant client who received an epidural? Epidural anesthesia can cause peripheral vasodilation. Maternal hypotension is the most serious adverse effect of epidural anesthesia during labor, which can reduce both maternal and fetal oxygenation. Minimizing damage to the skin Keeping fingernails short with rough edges filed help minimize excoriation from scratching the pruritic (Itch area). An immunocompromised client is displaying multiple symptoms suggesting an infection is occurring. What action should the PN take? Since the client has other symptoms of an infection: Cough 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. A client is found unresponsive. What should the PN do? When a client is found unresponsive, the PN should first obtain emergency help, a task that can be assigned to the UAP. What is the purpose of the Glasgow coma scale? The purpose of the Glasgow coma scale is to determine the level of consciousness. Although the status of the cranial nerves and the ability to respond verbally is evaluated using this scale. The primary assessment is to determine the level of consciousness. Where are the submandibular nodes located? The submandibular nodes are found beneath the mandible or lower jaw. What is an indication that a myocardial infarction occurred?
Elevations in the serum troponin 1 and Ck-MD indicated Myocardial cell damage which can cause and instability of the Myocardial cell membrane and can be precipitate life. The incidence of dysthymias in the immediate post-MI period is the greatest complication. Troponin 1, CK, CK-MB, and myoglobin. Evisceration Evisceration is the complete separation of a wound with protrusion of the viscera, which usually occurs 7-10 days Post Operative. A client is in buck's skin traction, where should the PN assess for infection? 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. What should be monitored in a client with hydrocephalus? The effectiveness of the shunt is determined by monitoring the daily head circumference, body temperature and intake and output. Glomerulonephritis and hematuria Presents with urine color changes due to hematuria, proteinuria and renal dysfunction that causes fluid retention edema and hypertension without or without oliguria. The typical motivator for the parents to seek medical help for a child is hematuria. What intervention should the PN use to help decrease the stress of a pediatric client? Common fears of toddlers include the loss of parents and fear of strangers. Allowing the child to be held by the primary caregiver is likely to help reduce the child's stress. Medication and photosensitivity Medications that cause photosensitivity increase sensitivity to sun light. The client should be reminded to protect skin from sunlight. A persistent dry cough is a side effect of what drug(s)? A persistent dry cough is a side effect of the antihypertensive agent quinapril, an angiotensin- Converting enzyme (ACE Inhibitor). What should the PN monitor in a client who is on antibiotics?
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. A client taking an SSRI presents with restlessness, tachycardia, fever, and elevated blood pressure. What should the PN do first? The PN should first contact the health care provider immediately and hold all paroxetine doses until further prescriptions are provided. Supporting a client after a mastectomy. What to do if the client doesn't want to talk? Accepting the client's refusal and offering to be available when the client is ready to talk about the mastectomy displays the PN's sensitivity, understanding and support of the client without judging or dismissing the clients attempt to cope. What should the PN expect from a client going through cocaine withdrawal? During cocaine withdrawal the PN should expect the client to experience intense cravings and a pattern of withdrawal symptoms described as a "Crash" Locations to check O2 saturation A finger or toe clip-on probe is most commonly used, but adhesive sensors can be applied to the nose or the forehead. A clip-on probe is available for use on an earlobe or an infant's foot. Live immunizations and steroids No live immunizations should be administered during therapy with steroids. Buck's skin traction 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. Pediatric patient and medication administration Be honest when talking to the child; tell the child it is medicine, not "juice" or "candy." Pediatric IM injection sites In infants, the lateral thigh (vastus lateralis muscle) should be used. In toddlers and preschoolers, the ventrogluteal area is the preferred site (lateral thigh can also be used).
In older children and adolescents, other regularly used injection sites may be used (ventrogluteal muscle is the safest; deltoid and dorsogluteal muscles may also be used). Dehiscence Dehiscence is a partial or complete separation of the outer wound layers, sometimes described as a "splitting open of the wound." Position for patients in cardiogenic shock Patients in cardiogenic shock are placed in Fowler's position to lower the diaphragm and increase oxygenation as long as they do not become too hypotensive. Vitamin D Found in fortified milk and margarine, cod liver oil, fatty fish, and eggs Vitamin K Found in leafy green vegetables and liver; synthesized by bacteria in the colon Vitamin B Found in muscle and organ meats, eggs, shellfish, and dairy products When should the PN contact the health care provider? Falls Deteriorate significantly or dies Has critical lab results Needs a prescription that requires clarification Leave against medical advice (AMA) or runs away Refuses key treatments Cancer of the larynx risk factors Men Smoking Chewing tabaco Alcohol When auscultating lungs with no air movement what should the PN expect to hear? Diminished or absent breath sounds. What could NG suctioning lead to?
Coffee ground emesis, black tarry stool. Hypospadias Abnormal congenital opening of the male urethra on the undersurface of the penis. The most common cause of pulmonary edema is Left-sided heart failure. Cardiovascular changes occur because Alkalosis increases myocardial irritability, especially when accompanied by hypokalemia. Metabolic alkalosis signs and symptoms Headache, irritability, lethargy, changes in level of consciousness, confusion, changes in heart rate, slow and shallow respirations with periods of apnea, nausea and vomiting, hyperactive reflexes, and numbness of the extremities. Wound care and pain management Assess pain before dressing changes. Administer pain meds 30-60 mins before dressing change. A moist environment promotes wound healing. Avoid overpacking the wound to minimize pressure. Symptoms of hypoxia Restlessness, confusion, change in level of consciousness, and cyanosis. Abnormal breathing patterns are Dyspnea; tachypnea; bradypnea; hyperventilation; and Cheyne-Stokes, Kussmaul, and Biot respirations. Documentation of a urinary catheter 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. Testicular self-examination (TSE) The best time to perform a TSE is after a warm shower, when the scrotal skin is relaxed. The scrotum is checked for color, contour, and skin breaks. Each testicle is gently palpated by grasping the scrotum in the center with the thumb and index finger Nursing process for all antibiotics
Monitor blood urea nitrogen (BUN), CBC, liver studies, particularly with IV medications. The most common general side effects are gastrointestinal upset, anorexia, nausea, diarrhea, rash, and photosensitivity. Nephrotic syndrome refers to A number of different types of kidney conditions that are distinguished by the presence of marked amounts of protein in the urine. Long-acting barbiturates are used As anticonvulsants to control and prevent grand mal seizures. Left ventricular failure Weakness Fatigue Dizziness Acute confusion Pulmonary congestion Breathlessness Oliguria (scant urine output) Third heart sound S3 gallop, is an early diastolic filling sound indicating an increase in left ventricular pressure. This sound is often the first sign of heart failure. Right-sided heart failure The patient has increased central venous pressure, jugular venous distention, abdominal engorgement, and dependent edema. Creatine kinase (CK) Male: 55-170 U/L Female: 30-135 U/L Glaucoma causes Tunnel Vision and is one of the leading causes of blindness worldwide. AV fistula assessment you should feel the thrill and hear the bruit, if not, this is an emergency, notify the MD. Thrill: Pulsation
