HESI CASE STUDY MOBILITY ACTUAL QUESTIONS AND ANSWERS
Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate to
severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should the
nurse draw up for administration? (Patient weighs 140 lbs on admission). - CORRECT ANSWER✅✅140
lb /2.2 lb = 63 kg
63 kg x 0.05 mg = 3.15 mg
3.15 mg / 2 ml = 1.575 ml
1.575 ml (Round) = 1.6 ml
Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first? -
CORRECT ANSWER✅✅C) Ask the client if he is aware of any allergies to medications.
Rationale:
This action should be taken first since this is the initial dose of a new medication. It is important to verify
any allergies. Clients sometimes recall additional allergies after the initial admission history has been
taken.
When the client's foot pain is controlled, which nursing diagnosis should take priority? - CORRECT
ANSWER✅✅C) Impaired physical mobility.
Rationale:
The client's limited activities support this nursing diagnosis. Improving mobility is a nursing priority to
prevent the many potential complications of immobility.
Which goal is correct for the client's diagnosis of impaired physical mobility? - CORRECT 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 the client is to achieve and sets a realistic deadline.
, Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the
client's legs? (Select all that apply. One, some, or all options may be correct.) - CORRECT ANSWER✅✅B)
Teach the client to dorsal flex and plantar flex his feet while in the bed and chair.
C) Instruct the client to wear sequential compression stockings.
E) Explain that enoxaparin injections will be administered routinely.
Rationale:
This action stimulates circulation by contracting calf muscles, which increases the venous return of
blood to the heart. These decreases pooling of blood in the legs, which helps VTE in the legs. Sequential
compression devices (SCD) promote venous blood flow, preventing VTE. Enoxaparin is an anticoagulant
that is administered to reduce the risk of VTE.
The nurse is observing a student nurse perform a peripheral assessment on the client. Which action
requires the nurse to intervene? - CORRECT ANSWER✅✅C) Assessing the Homan's sign in bilateral
extremities.
Rationale:
Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible clot
dislodgment.
Which instruction should the nurse give to the nursing student for positioning the client's legs when he
is sitting? - CORRECT ANSWER✅✅A) Use two pillows and place one lengthwise under each calf.
Rationale:
This method provides a slight elevation of the lower legs for comfort but avoids pressure behind the
knees, which would adversely decrease venous return and decrease the risk for venous thrombosis.
The client is wearing thigh-high Anti embolic hose prescribed by the Healthcare provider (HCP). The
nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible
thrombophlebitis that should be reported to the HCP? - CORRECT ANSWER✅✅D) Unilateral calf edema.
Rationale:
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the HCP.
Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate to
severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should the
nurse draw up for administration? (Patient weighs 140 lbs on admission). - CORRECT ANSWER✅✅140
lb /2.2 lb = 63 kg
63 kg x 0.05 mg = 3.15 mg
3.15 mg / 2 ml = 1.575 ml
1.575 ml (Round) = 1.6 ml
Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first? -
CORRECT ANSWER✅✅C) Ask the client if he is aware of any allergies to medications.
Rationale:
This action should be taken first since this is the initial dose of a new medication. It is important to verify
any allergies. Clients sometimes recall additional allergies after the initial admission history has been
taken.
When the client's foot pain is controlled, which nursing diagnosis should take priority? - CORRECT
ANSWER✅✅C) Impaired physical mobility.
Rationale:
The client's limited activities support this nursing diagnosis. Improving mobility is a nursing priority to
prevent the many potential complications of immobility.
Which goal is correct for the client's diagnosis of impaired physical mobility? - CORRECT 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 the client is to achieve and sets a realistic deadline.
, Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the
client's legs? (Select all that apply. One, some, or all options may be correct.) - CORRECT ANSWER✅✅B)
Teach the client to dorsal flex and plantar flex his feet while in the bed and chair.
C) Instruct the client to wear sequential compression stockings.
E) Explain that enoxaparin injections will be administered routinely.
Rationale:
This action stimulates circulation by contracting calf muscles, which increases the venous return of
blood to the heart. These decreases pooling of blood in the legs, which helps VTE in the legs. Sequential
compression devices (SCD) promote venous blood flow, preventing VTE. Enoxaparin is an anticoagulant
that is administered to reduce the risk of VTE.
The nurse is observing a student nurse perform a peripheral assessment on the client. Which action
requires the nurse to intervene? - CORRECT ANSWER✅✅C) Assessing the Homan's sign in bilateral
extremities.
Rationale:
Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible clot
dislodgment.
Which instruction should the nurse give to the nursing student for positioning the client's legs when he
is sitting? - CORRECT ANSWER✅✅A) Use two pillows and place one lengthwise under each calf.
Rationale:
This method provides a slight elevation of the lower legs for comfort but avoids pressure behind the
knees, which would adversely decrease venous return and decrease the risk for venous thrombosis.
The client is wearing thigh-high Anti embolic hose prescribed by the Healthcare provider (HCP). The
nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible
thrombophlebitis that should be reported to the HCP? - CORRECT ANSWER✅✅D) Unilateral calf edema.
Rationale:
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the HCP.
