FUND-HESI mobility exam questions
with verified answers
.
Which instruction(s) should the nurse convey to help prevent venous thromboembolism
(VTE) in Mr. Matthew's legs? - Answer--Teach Mr. Matthew to dorsal flex and plantar
flex his feet while in the bed and chair.
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.
-Explain enoxaparin (Lovenox) injections will be administered routinely.
Lovenox is an anticoagulant administered to reduce the rick of venous
thromboembolism.
How should the nurse document the completed client teaching? - Answer-Dorsal and
plantar flexion demonstrated to client and returned correctly. States he will perform 10
times an hour.
This represents a complete documentation, which includes the content taught and a
statement of the client's understanding after the teaching.
The healthcare provider has prescribed thigh-high antiembolic hose (TEDs) for Mr.
Matthew. The nurse assesses the client's legs every 8 hours.
Which assessment finding(s) reflects signs of possible thrombophlebitis that should be
reported to the healthcare provider? - Answer-Unilateral calf edema.
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be
reported to the healthcare provider.
What instruction should the nurse give to the unlicensed assistive personnel (UAP) for
positioning Mr. Matthew's legs? - Answer-Use 2 pillows and place one lengthwise under
each calf.
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
of venous thrombosis.
Mr. Matthew is 6 feet 2 inches tall and weighs 140 pounds. The nurse calculates his
Body Mass Index (BMI) as 18.The nurse continues the nutritional assessment.Mrs.
Matthew tells the nurse that she cooks every day, but Mr. Matthew does not even eat
his favorite foods anymore, although he does drink a lot of diet colas.
Which nursing diagnosis best applies to Mr. Matthew's nutritional assessment? -
Answer-Imbalanced nutrition: less than body requirements.
, The choice of this diagnosis is supported by the evidence of his BMI , which is below
18.5, placing him in the underweight category, and his lack of intake of nutrients.
Mr. Matthew indicates an interest in improving his nutrition. He says that he is worried
because he has heard that bones weaken when people stay in bed. He asks which food
will help his bones. The nurse explains that osteoporosis can develop from a sedentary
lifestyle.
The nurse instructs Mr. Matthew to increase his intake of which foods to prevent a
decrease in bone density? - Answer-Calcium-rich foods.
Calcium must be deposited in the bones to increase bone density.
The nurse is helping Mr. Matthew choose foods from a regular (unrestricted) diet menu
for tomorrow's breakfast. Mr. Matthew says he will try to eat more, even though he still
doesn't have much of an appetite.
Which foods should the nurse encourage? - Answer-Milk, oatmeal, and an orange.
These are nutrient-rich choices. Milk is a primary source of calcium to prevent
osteoporosis. The milk and oatmeal provide protein. The orange provides vitamin C.
Added benefits are vitamin A from the orange and fiber from the oatmeal and the
orange.
Mr. Matthew tells the nurse that he had a war injury resulting in right leg weakness. He
states, "It gives out on me sometimes." In spite of the weakness in his leg, the nurse
encourages Mr. Matthew to transfer from the bed to the chair.
How should the nurse teach the unlicensed assistive personnel (UAP) to position the
chair to ensure a safe transfer? - Answer-Position the chair at a 45-degree angle to the
bed on Mr. Matthew's left side.
Placing the chair at a 45-degree angle on Mr. Matthew's stronger left side provides for a
safe transfer because it allows him to pivot easily from the bed into the chair.
The nurse is in the room when Mr. Matthew quickly gets up out of bed to go to the
bathroom. With the nurse's assistance, he walks about 5 feet from the bed, where he
stops and states, "I feel faint." He then starts to fall.
What is the priority nursing action? - Answer-Gently lower Mr. Matthew to the floor.
This is the priority nursing action to prevent injury to the client and the nurse. Lowering
Mr. Matthew to the floor should be done when he cannot support his own weight.
After sitting on the floor for a few minutes, Mr. Matthew is helped to a standing position
by the nurse and the UAP. He is able to walk to the bathroom and back to bed without
further problems. After Mr. Matthew is safely back in bed, he asks the nurse, "What
caused me to feel faint?"
with verified answers
.
Which instruction(s) should the nurse convey to help prevent venous thromboembolism
(VTE) in Mr. Matthew's legs? - Answer--Teach Mr. Matthew to dorsal flex and plantar
flex his feet while in the bed and chair.
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.
-Explain enoxaparin (Lovenox) injections will be administered routinely.
Lovenox is an anticoagulant administered to reduce the rick of venous
thromboembolism.
How should the nurse document the completed client teaching? - Answer-Dorsal and
plantar flexion demonstrated to client and returned correctly. States he will perform 10
times an hour.
This represents a complete documentation, which includes the content taught and a
statement of the client's understanding after the teaching.
The healthcare provider has prescribed thigh-high antiembolic hose (TEDs) for Mr.
Matthew. The nurse assesses the client's legs every 8 hours.
Which assessment finding(s) reflects signs of possible thrombophlebitis that should be
reported to the healthcare provider? - Answer-Unilateral calf edema.
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be
reported to the healthcare provider.
What instruction should the nurse give to the unlicensed assistive personnel (UAP) for
positioning Mr. Matthew's legs? - Answer-Use 2 pillows and place one lengthwise under
each calf.
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
of venous thrombosis.
Mr. Matthew is 6 feet 2 inches tall and weighs 140 pounds. The nurse calculates his
Body Mass Index (BMI) as 18.The nurse continues the nutritional assessment.Mrs.
Matthew tells the nurse that she cooks every day, but Mr. Matthew does not even eat
his favorite foods anymore, although he does drink a lot of diet colas.
Which nursing diagnosis best applies to Mr. Matthew's nutritional assessment? -
Answer-Imbalanced nutrition: less than body requirements.
, The choice of this diagnosis is supported by the evidence of his BMI , which is below
18.5, placing him in the underweight category, and his lack of intake of nutrients.
Mr. Matthew indicates an interest in improving his nutrition. He says that he is worried
because he has heard that bones weaken when people stay in bed. He asks which food
will help his bones. The nurse explains that osteoporosis can develop from a sedentary
lifestyle.
The nurse instructs Mr. Matthew to increase his intake of which foods to prevent a
decrease in bone density? - Answer-Calcium-rich foods.
Calcium must be deposited in the bones to increase bone density.
The nurse is helping Mr. Matthew choose foods from a regular (unrestricted) diet menu
for tomorrow's breakfast. Mr. Matthew says he will try to eat more, even though he still
doesn't have much of an appetite.
Which foods should the nurse encourage? - Answer-Milk, oatmeal, and an orange.
These are nutrient-rich choices. Milk is a primary source of calcium to prevent
osteoporosis. The milk and oatmeal provide protein. The orange provides vitamin C.
Added benefits are vitamin A from the orange and fiber from the oatmeal and the
orange.
Mr. Matthew tells the nurse that he had a war injury resulting in right leg weakness. He
states, "It gives out on me sometimes." In spite of the weakness in his leg, the nurse
encourages Mr. Matthew to transfer from the bed to the chair.
How should the nurse teach the unlicensed assistive personnel (UAP) to position the
chair to ensure a safe transfer? - Answer-Position the chair at a 45-degree angle to the
bed on Mr. Matthew's left side.
Placing the chair at a 45-degree angle on Mr. Matthew's stronger left side provides for a
safe transfer because it allows him to pivot easily from the bed into the chair.
The nurse is in the room when Mr. Matthew quickly gets up out of bed to go to the
bathroom. With the nurse's assistance, he walks about 5 feet from the bed, where he
stops and states, "I feel faint." He then starts to fall.
What is the priority nursing action? - Answer-Gently lower Mr. Matthew to the floor.
This is the priority nursing action to prevent injury to the client and the nurse. Lowering
Mr. Matthew to the floor should be done when he cannot support his own weight.
After sitting on the floor for a few minutes, Mr. Matthew is helped to a standing position
by the nurse and the UAP. He is able to walk to the bathroom and back to bed without
further problems. After Mr. Matthew is safely back in bed, he asks the nurse, "What
caused me to feel faint?"
