HESI: Mobility Exam Questions with
Correct Answers
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 Mr. Matthew is to achieve
and sets a realistic deadline. "A" is wrong because it is an uncompleted goal. "B" and
"C" are wrong because they are nursing actions and not a client goal.
Mr. Matthew is reluctant to move in the bed or move to the chair. He likes his wife to
place a pillow under his knee. The nurse performs a physical assessment, which
reveals diminished dorsalis pedis pulses bilaterally. Which instruction(s) should the
nurse convey to help prevent venous thromboembolism (VTE) in Mr. Matthew's legs?
(Select all that apply)
A. Encourage Mr. Matthew to cough and breathe deeply 10 times an hour.
B. Teach Mr. Matthew to dorsal flew and planter flex his feet while in the bed and chair.
C. Instruct Mr. Matthew to change positions every 2 hours in the bed or chair.
D. Advise Mr. Matthew to eat well-balanced meals and between-meals snacks.
E. Explain enoxaparin (Lovenox) injections will be administered routinely. - Answer-B.
Teach Mr. Matthew to dorsal flex and plantar flex his feet while in the bed and chair.
Rationale: 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.
E. Explain enoxaparin (Lovenox) injections will be administered routinely.
Rationale: Lovenox is an anticoagulant administered to reduce the risk of venous
thromboembolism.
"A" is not right because this action helps prevent pneumonia, not venous return. "C" is
not right because this action is more specific for preventing skin breakdown and
pneumonia than venous thromboembolism formation in the legs. "D" is not right
because it will not prevent thromboembolism.
6. How should the nurse document the completed client teaching?
A. Nurse demonstrated foot exercises to client to be done 10 times an hour in room.
Tolerated teaching well.
B. Nurse explained foot exercises to client and wife.
C. Dorsal and plantar flexion demonstrated to client and returned correctly. States he
will perform 10 times an hour.
, D. Dorsal and plantar flexion taught to client and wife. Both stated their appreciation for
the attention. - Answer-C. Dorsal and plantar flexion demonstrated to client and
returned correctly. States he will perform 10 times an hour.
Rationale: 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?
A. Negative for paresthesia.
B. Bounding pedal pulse.
C. Negative for pallor.
D. Unilateral calf edema. - Answer-D. Unilateral calf edema.
Rationale: Edema or swelling of one calf is a possible sign of thrombophlebitis that
should be reported to the healthcare provider. "A" is not right because paresthesia is an
abnormal sensation, such as tingling or numbness, it is not a warning sign of thrombus
formation. "B" is not right because it is not related to thrombus formation. "C" is not right
because lack of paleness is a normal finding.
What instruction should the nurse give to the unlicensed assistive personnel (UAP) for
positioning Mr. Matthew's legs?
A. Use 2 pillows and place one lengthwise under each calf.
B. Let him position himself with pillows until he is comfortable.
C. Allow him to use bed controls to markedly flex his knees.
D. Encourage him to keep his legs flat and not bend his knees. - Answer-A. Use 2
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 of thrombus formation. "B" is not right because although comfort is
important, the client needs education on the best position to decrease risk of thrombus
formation. "C" is not right because marked flexion of the knees decreases circulation in
the legs and increases the risk for thrombus formation.
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?
A. Milk, oatmeal, and an orange.
B. Toasted white bread and tea.
C. Biscuit, jelly, and coffee.
Correct Answers
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 Mr. Matthew is to achieve
and sets a realistic deadline. "A" is wrong because it is an uncompleted goal. "B" and
"C" are wrong because they are nursing actions and not a client goal.
Mr. Matthew is reluctant to move in the bed or move to the chair. He likes his wife to
place a pillow under his knee. The nurse performs a physical assessment, which
reveals diminished dorsalis pedis pulses bilaterally. Which instruction(s) should the
nurse convey to help prevent venous thromboembolism (VTE) in Mr. Matthew's legs?
(Select all that apply)
A. Encourage Mr. Matthew to cough and breathe deeply 10 times an hour.
B. Teach Mr. Matthew to dorsal flew and planter flex his feet while in the bed and chair.
C. Instruct Mr. Matthew to change positions every 2 hours in the bed or chair.
D. Advise Mr. Matthew to eat well-balanced meals and between-meals snacks.
E. Explain enoxaparin (Lovenox) injections will be administered routinely. - Answer-B.
Teach Mr. Matthew to dorsal flex and plantar flex his feet while in the bed and chair.
Rationale: 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.
E. Explain enoxaparin (Lovenox) injections will be administered routinely.
Rationale: Lovenox is an anticoagulant administered to reduce the risk of venous
thromboembolism.
"A" is not right because this action helps prevent pneumonia, not venous return. "C" is
not right because this action is more specific for preventing skin breakdown and
pneumonia than venous thromboembolism formation in the legs. "D" is not right
because it will not prevent thromboembolism.
6. How should the nurse document the completed client teaching?
A. Nurse demonstrated foot exercises to client to be done 10 times an hour in room.
Tolerated teaching well.
B. Nurse explained foot exercises to client and wife.
C. Dorsal and plantar flexion demonstrated to client and returned correctly. States he
will perform 10 times an hour.
, D. Dorsal and plantar flexion taught to client and wife. Both stated their appreciation for
the attention. - Answer-C. Dorsal and plantar flexion demonstrated to client and
returned correctly. States he will perform 10 times an hour.
Rationale: 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?
A. Negative for paresthesia.
B. Bounding pedal pulse.
C. Negative for pallor.
D. Unilateral calf edema. - Answer-D. Unilateral calf edema.
Rationale: Edema or swelling of one calf is a possible sign of thrombophlebitis that
should be reported to the healthcare provider. "A" is not right because paresthesia is an
abnormal sensation, such as tingling or numbness, it is not a warning sign of thrombus
formation. "B" is not right because it is not related to thrombus formation. "C" is not right
because lack of paleness is a normal finding.
What instruction should the nurse give to the unlicensed assistive personnel (UAP) for
positioning Mr. Matthew's legs?
A. Use 2 pillows and place one lengthwise under each calf.
B. Let him position himself with pillows until he is comfortable.
C. Allow him to use bed controls to markedly flex his knees.
D. Encourage him to keep his legs flat and not bend his knees. - Answer-A. Use 2
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 of thrombus formation. "B" is not right because although comfort is
important, the client needs education on the best position to decrease risk of thrombus
formation. "C" is not right because marked flexion of the knees decreases circulation in
the legs and increases the risk for thrombus formation.
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?
A. Milk, oatmeal, and an orange.
B. Toasted white bread and tea.
C. Biscuit, jelly, and coffee.
