PN EXIT HESI / RATIONALES|UPDATED&VERIFIED|100% SOLVED|GUARANTEED SUCCESS

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? 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.