HESI Case Study: Mobility Exam Questions with Correct Answers

HESI Case Study: Mobility Exam Questions with Correct Answers 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? - 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? - 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? - 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 is prescribed enoxaparin while admitted to hospital per protocol. The dose is 1mg/kg subcutaneously every 12 hours and the client weighs 140 lbs. Dose available is 80mg per 0.8 mL. How many milliliters will the nurse administer to the client? (Enter the numeric value only. If rounding is necessary, round to the nearest tenth.) - Answer-140 lb / 2.2 lb = 63 kg 63kg x 1 mg = 63 mg 63 mg/ 80 mg = 0.7875 0.7875 x 0.8 ml = 0.63 ml 0.63 ml (Round) = 0.6 ml