1|Page
HESI LPN-ADN MOBILITY|| Verified Questions And
Answers Practice Questions with Solutions Newest |
Already Graded A+||Newest Exam!!!
Mr. Matthew states the pain level in his right foot is 8 on a
scale of 1-10. He says he has been favoring his foot by
staying in bed the past week. In planning his care, which
nursing diagnosis should take priority?
A. Risk for caregiver role strain.
B. Risk for social isolation.
C. Impaired physical mobility.
D. Imbalanced nutrition: more than body requirements. -
Answer-C. Impaired physical mobility.
Rationale: Mr. Matthew's limited activities support this
nursing diagnosis. Improving mobility is a nursing priority
to prevent the many potential complications.
In developing a plan of care, the nurse consults with Mr.
Matthew to identify a short-term goal. Which goal is
correct for Mr. Matthew's diagnosis for impaired mobility?
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A. The client will demonstrate better mobility by time of
discharge.
B. The nurse will reposition the client every 2 hours while
awake.
C. The client will sit in the chair for each meal beginning
on the day of admission.
D. The nurse will assist the client to ambulate in the hall by
the second hospital day. - Answer-C. The client will sit in
the chair for each meal beginning on the day of admission.
Rationale: This is a correctly stated goal. The client is
always the subject of the goal, and the action is always
measurable. This goal includes what Mr. Matthew is to
achieve and sets a realistic deadline. "A" is wrong
because it is an uncompleted goal. "B" and "C" are wrong
because they are nursing actions and not a client goal.
Mr. Matthew is reluctant to move in the bed or move to the
chair. He likes his wife to place a pillow under his knee.
The nurse performs a physical assessment, which reveals
diminished dorsalis pedis pulses bilaterally. Which
instruction(s) should the nurse convey to help prevent
venous thromboembolism (VTE) in Mr. Matthew's legs?
(Select all that apply)
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A. Encourage Mr. Matthew to cough and breathe deeply
10 times an hour.
B. Teach Mr. Matthew to dorsal flew and planter flex his
feet while in the bed and chair.
C. Instruct Mr. Matthew to change positions every 2 hours
in the bed or chair.
D. Advise Mr. Matthew to eat well-balanced meals and
between-meals snacks.
E. Explain enoxaparin (Lovenox) injections will be
administered routinely. - Answer-B. Teach Mr. Matthew to
dorsal flex and plantar flex his feet while in the bed and
chair.
Rationale: This action stimulates circulation by contracting
calf muscles, which increases the venous return of blood
to the heart. This decreases pooling of blood in the legs,
which helps prevent venous thromboembolism in the legs.
E. Explain enoxaparin (Lovenox) injections will be
administered routinely.
, 4|Page
Rationale: Lovenox is an anticoagulant administered to
reduce the risk of venous thromboembolism.
"A" is not right because this action helps prevent
pneumonia, not venous return. "C" is not right because
this action is more specific for preventing skin breakdown
and pneumonia than venous thromboembolism formation
in the legs. "D" is not right because it will not prevent
thromboembolism.
Mr. Matthew tells the nurse that he has never been
hospitalized. He appears anxious and frequently turns to
his wife for reassurance. What is the best response by the
nurse?
A. "Is there anything you would like to ask your healthcare
provider?"
B. "What concerns do you have about being hospitalized."
C. "We give good care to all our clients in the hospital."
D. "Your healthcare provider the chosen the best hospital
in the city." - Answer-B. "What concerns do you have
about being hospitalized?"
HESI LPN-ADN MOBILITY|| Verified Questions And
Answers Practice Questions with Solutions Newest |
Already Graded A+||Newest Exam!!!
Mr. Matthew states the pain level in his right foot is 8 on a
scale of 1-10. He says he has been favoring his foot by
staying in bed the past week. In planning his care, which
nursing diagnosis should take priority?
A. Risk for caregiver role strain.
B. Risk for social isolation.
C. Impaired physical mobility.
D. Imbalanced nutrition: more than body requirements. -
Answer-C. Impaired physical mobility.
Rationale: Mr. Matthew's limited activities support this
nursing diagnosis. Improving mobility is a nursing priority
to prevent the many potential complications.
In developing a plan of care, the nurse consults with Mr.
Matthew to identify a short-term goal. Which goal is
correct for Mr. Matthew's diagnosis for impaired mobility?
,2|Page
A. The client will demonstrate better mobility by time of
discharge.
B. The nurse will reposition the client every 2 hours while
awake.
C. The client will sit in the chair for each meal beginning
on the day of admission.
D. The nurse will assist the client to ambulate in the hall by
the second hospital day. - Answer-C. The client will sit in
the chair for each meal beginning on the day of admission.
Rationale: This is a correctly stated goal. The client is
always the subject of the goal, and the action is always
measurable. This goal includes what Mr. Matthew is to
achieve and sets a realistic deadline. "A" is wrong
because it is an uncompleted goal. "B" and "C" are wrong
because they are nursing actions and not a client goal.
Mr. Matthew is reluctant to move in the bed or move to the
chair. He likes his wife to place a pillow under his knee.
The nurse performs a physical assessment, which reveals
diminished dorsalis pedis pulses bilaterally. Which
instruction(s) should the nurse convey to help prevent
venous thromboembolism (VTE) in Mr. Matthew's legs?
(Select all that apply)
,3|Page
A. Encourage Mr. Matthew to cough and breathe deeply
10 times an hour.
B. Teach Mr. Matthew to dorsal flew and planter flex his
feet while in the bed and chair.
C. Instruct Mr. Matthew to change positions every 2 hours
in the bed or chair.
D. Advise Mr. Matthew to eat well-balanced meals and
between-meals snacks.
E. Explain enoxaparin (Lovenox) injections will be
administered routinely. - Answer-B. Teach Mr. Matthew to
dorsal flex and plantar flex his feet while in the bed and
chair.
Rationale: This action stimulates circulation by contracting
calf muscles, which increases the venous return of blood
to the heart. This decreases pooling of blood in the legs,
which helps prevent venous thromboembolism in the legs.
E. Explain enoxaparin (Lovenox) injections will be
administered routinely.
, 4|Page
Rationale: Lovenox is an anticoagulant administered to
reduce the risk of venous thromboembolism.
"A" is not right because this action helps prevent
pneumonia, not venous return. "C" is not right because
this action is more specific for preventing skin breakdown
and pneumonia than venous thromboembolism formation
in the legs. "D" is not right because it will not prevent
thromboembolism.
Mr. Matthew tells the nurse that he has never been
hospitalized. He appears anxious and frequently turns to
his wife for reassurance. What is the best response by the
nurse?
A. "Is there anything you would like to ask your healthcare
provider?"
B. "What concerns do you have about being hospitalized."
C. "We give good care to all our clients in the hospital."
D. "Your healthcare provider the chosen the best hospital
in the city." - Answer-B. "What concerns do you have
about being hospitalized?"
