HESI EXIT EXAM- LATEST 2021 COMPLETE QUESTIONS & ANSWERS.

a stroke. The health careprovider writes orders for “ROM as needed.” What should the nurse donext?a.Restrict patient’s mobility as much aspossible.b.Realize the patient is unable to moveextremities.c.Move all the patient’sextremities.d.Further assess thepatient.ANS: DFurther assessment of the patient is needed to determine what the patient is able to perform. Some patients are able to move some joints actively, whereasthe nurse passively moves others. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as health and mobility allow.6.AnurseisassessingpressurepointsinapatientplacedintheSims’position.Whichareaswillthenurse observe?a.Chin, elbow,hipsb.Ileum, clavicle,kneesc.Shoulder, anterior iliac spine,anklesd.Occipital region of the head, coccyx,heelsANS: BIn the Sims’ position pressure points include the ileum, humerus, clavicle, knees, and ankles. The lateral position pressure points include the ear, shoulder, anterior iliac spine, and ankles. The prone position pressure points include the chin, elbows, female breasts, hips, knees, and toes. Supine position pressure points include the occipital region of the head, vertebrae, coccyx, elbows, and heels.7.The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient’s nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?a.Obtain assistance and physically transfer the patient to thechair.b.Assist with ambulation and measure how far the patientwalks.Give pain medication after ambulation so the patient will have .d.Bring the patient to the cafeteria for group instruction onambulation.ANS: BAssist with walking and measure how far the patient walks to quantify progress. The nurse should allow the patient to do as much for self as possible. Therefore, the nurse should observe the patient transferring from the bed to the chair using the walker and should provide assistance as needed. The patient should be encouragedto use adequate pain medication to decrease the effects of pain and to increase mobility. The patient should be instructed on safe transfer and ambulation techniques in an environment with few distractions, not in the cafeteria.