HESI Mobility Case Study Exam Question and Answers

HESI Mobility Case Study Exam Question and Answers The pt's limited activity support this. This is a nursing priority to prevent many complications. #1 exists for pt's wife, not priority. #2 can occur, but not the priority. #4 has no supporting evidence. Which goal is correct for the client's problem of impaired physical mobility? O The client will transfer to the chair with assist of one person. O The nurse will reposition the client every hour while the client is awake. O The client will sit in the chair for each meal beginning on the day of admission. O The nurse will assist the client to ambulate in the hall by second hospital day. - Answer-The client will sit in the chair for each meal beginning on the day of admission. This is a pt goal: what pt is to achieve & sets a realistic deadline. Subject = pt; action = measurable. #1 is an incomplete goal. #2 is a nursing action, not a measurable goal. #4 is a nursing action, not a pt goal. Section 2 Prevention of Venous Thrombosis - Answer-The pt is reluctant to move in bed or to chair. He likes spouse to place pillow beneath knee. The RN informs them that the PCP ordered enoxaparin injsterm-4 & antiembolic stockings. The RN performs a focused PA, revealing diminished dorsalis pedis pulses BIL. Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? Select all that apply. O Encourage the client to use the incentive spirometer 10 times an hour while awake. O Teach the client to dorsal flex and plantar flex his feet while in bed and chair. O Instruct the client to wear sequential compression stockings. O Advise the client to try not to move and cause pain in his foot wound. O Explain that enoxaparin injections will be administered routinely. - Answer-- Teach the client to dorsal flex and plantar flex his feet while in bed and chair. - Instruct the client to wear sequential compression stockings. - Explain that enoxaparin injections will be administered routinely. #2 promotes circulation by contracting calf muscles, inc. venous return. Dec. blood pooling in legs. #3 SCD promote venous flow. #5 is an anticoag.