Rationals - exit hesi V1 2024 (100%
Verified)
Rational - ANS-Stomatitis, or inflammation of the oral mucosa, can cause pain and
resultant difficulty in swallowing. The PN should gather information related to the client's
ability to swallow
Rational - ANS-After a flooding disaster, prescriptions, such as ciprofloxacin, are
commonly prescribed for traveler's diarrhea or drinking water contamination, and the
prescription should be completed to effect adequate prophylaxis or treatment. Hydration
is key in managing diarrhea, but clients should be reminded to drink only clean water
that has been boiled, disinfected with iodine or chlorine, or bottled drinking solutions.
Handwashing is a primary disease transmission prevention technique.
Rational - ANS-The sublingual route (SL) refers to placement of the medication under
the tongue for absorption. This route can still be used without any adaption.
Rational - ANS-A client with contractions that are 7 to 15 minutes apart, lasting 20 to 30
seconds with mild intensity by palpation is experiencing mild irregular contractions
which are likely Braxton-Hicks. 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. This client is not yet in active labor and would probably be
more comfortable at home until she is in active labor.
Rational - ANS-These findings should be documented and reported to the client's
primary nurse. The PN should enter computer documentation of the witnessed findings
and actions, using objective statements that include factual descriptions of the
witnessed event.
Rational - ANS-Complications of colonoscopy with surgical excision of polyps can
include bowel perforation or bleeding from the biopsy site. The client who is bleeding
after a polypectomy needs immediate intervention by the PN.
Rational - ANS-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
Rational - ANS-Nasogastric suctioning increases the loss of gastric secretions and
contributes to fluid and electrolyte imbalances which can cause metabolic alkalosis.
Metabolic alkalosis may result in hypokalemia. The client's cardiovascular function
should be monitored for signs an elevated pulse and cardiac dysrhythmias (such as
PVCs) related to fluid loss and potassium imbalances.
Rational - ANS-The client is exhibiting localized phlebitis at the IV access site and signs
of septicemia, a potentially life-threatening condition that should be reported to the
charge nurse immediately. Once the findings are reported, the PN can complete
additional assessments and administer PRN medications as indicated. After the IV is
removed and replaced, a warm compress may provide relief of the localized phlebitis.
Rational - ANS-Callus formation is visualized on x-ray and is a normal stage of bone
repair that indicates osteoblast, blood vessels, and fibroblasts are surrounding the
fracture site and initiating cartilage synthesis, bone formation, and healing. The PN
should explain the normal healing process
Rational - ANS-During cocaine withdrawal, the PN should expect the client to
experience intense cravings and pattern of withdrawal symptoms described as a "crash"
Rational - ANS-A persistent dry cough is a side effect of the antihypertensive agent
quinapril, an angiotensin-converting enzyme (ACE inhibitor)
Rational - ANS-Singed nasal hairs, smoky breath, and darkened membranes around
the nose and mouth are indicators of a potential inhalation injury which can lead to
respiratory distress. The priority nursing problem the PN should include is ineffective
airway clearance.
Rational - ANS-Pilocarpine is used in glaucoma to contract iris sphincter muscle and to
open the trabecular meshwork spaces. This helps with the drainage of aqueous humor
and decreases intraocular pressure in the eye.
Rational - ANS-The application of heat is a treatment used for low back pain. A
prescription from a HCP must be obtained to starting the treatment.
Rational - ANS-Ondansetron is an antiemetic prior to chemotherapy to prevent
post-treatment nausea and vomiting.
Rational - ANS-To prevent aspiration when providing oral care to an unconscious client,
Verified)
Rational - ANS-Stomatitis, or inflammation of the oral mucosa, can cause pain and
resultant difficulty in swallowing. The PN should gather information related to the client's
ability to swallow
Rational - ANS-After a flooding disaster, prescriptions, such as ciprofloxacin, are
commonly prescribed for traveler's diarrhea or drinking water contamination, and the
prescription should be completed to effect adequate prophylaxis or treatment. Hydration
is key in managing diarrhea, but clients should be reminded to drink only clean water
that has been boiled, disinfected with iodine or chlorine, or bottled drinking solutions.
Handwashing is a primary disease transmission prevention technique.
Rational - ANS-The sublingual route (SL) refers to placement of the medication under
the tongue for absorption. This route can still be used without any adaption.
Rational - ANS-A client with contractions that are 7 to 15 minutes apart, lasting 20 to 30
seconds with mild intensity by palpation is experiencing mild irregular contractions
which are likely Braxton-Hicks. 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. This client is not yet in active labor and would probably be
more comfortable at home until she is in active labor.
Rational - ANS-These findings should be documented and reported to the client's
primary nurse. The PN should enter computer documentation of the witnessed findings
and actions, using objective statements that include factual descriptions of the
witnessed event.
Rational - ANS-Complications of colonoscopy with surgical excision of polyps can
include bowel perforation or bleeding from the biopsy site. The client who is bleeding
after a polypectomy needs immediate intervention by the PN.
Rational - ANS-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
Rational - ANS-Nasogastric suctioning increases the loss of gastric secretions and
contributes to fluid and electrolyte imbalances which can cause metabolic alkalosis.
Metabolic alkalosis may result in hypokalemia. The client's cardiovascular function
should be monitored for signs an elevated pulse and cardiac dysrhythmias (such as
PVCs) related to fluid loss and potassium imbalances.
Rational - ANS-The client is exhibiting localized phlebitis at the IV access site and signs
of septicemia, a potentially life-threatening condition that should be reported to the
charge nurse immediately. Once the findings are reported, the PN can complete
additional assessments and administer PRN medications as indicated. After the IV is
removed and replaced, a warm compress may provide relief of the localized phlebitis.
Rational - ANS-Callus formation is visualized on x-ray and is a normal stage of bone
repair that indicates osteoblast, blood vessels, and fibroblasts are surrounding the
fracture site and initiating cartilage synthesis, bone formation, and healing. The PN
should explain the normal healing process
Rational - ANS-During cocaine withdrawal, the PN should expect the client to
experience intense cravings and pattern of withdrawal symptoms described as a "crash"
Rational - ANS-A persistent dry cough is a side effect of the antihypertensive agent
quinapril, an angiotensin-converting enzyme (ACE inhibitor)
Rational - ANS-Singed nasal hairs, smoky breath, and darkened membranes around
the nose and mouth are indicators of a potential inhalation injury which can lead to
respiratory distress. The priority nursing problem the PN should include is ineffective
airway clearance.
Rational - ANS-Pilocarpine is used in glaucoma to contract iris sphincter muscle and to
open the trabecular meshwork spaces. This helps with the drainage of aqueous humor
and decreases intraocular pressure in the eye.
Rational - ANS-The application of heat is a treatment used for low back pain. A
prescription from a HCP must be obtained to starting the treatment.
Rational - ANS-Ondansetron is an antiemetic prior to chemotherapy to prevent
post-treatment nausea and vomiting.
Rational - ANS-To prevent aspiration when providing oral care to an unconscious client,
