HESI CASE STUDY 1 MOBILITY
QUESTIONS AND COMPLETE
SOLUTIONS GRADED A+
Your Exam Plug
, Before giving the initial dose of pain meds or antibiotic, which action should the nurse take 1st? -
Answer: Ask about any knowledge of allergies to any medications.
Which instructions should the nurse convey to help prevent VTE (Venous Thrombosis) in the client's
legs? (Select all that apply. One, some, or all options may be correct.) - Answer: B) Teach the client to
dorsal flex and plantar flex his feet while in the bed and chair.
C) Instruct the client to wear sequential compression stockings.
E) Explain that enoxaparin injections will be administered routinely.
Rationale:
B. 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 VTE in the legs.
C. Sequential compression devices (SCD) promote venous blood flow, preventing VTE.
E. 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: 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: 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 antiembolic 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: Unilateral calf edema.
QUESTIONS AND COMPLETE
SOLUTIONS GRADED A+
Your Exam Plug
, Before giving the initial dose of pain meds or antibiotic, which action should the nurse take 1st? -
Answer: Ask about any knowledge of allergies to any medications.
Which instructions should the nurse convey to help prevent VTE (Venous Thrombosis) in the client's
legs? (Select all that apply. One, some, or all options may be correct.) - Answer: B) Teach the client to
dorsal flex and plantar flex his feet while in the bed and chair.
C) Instruct the client to wear sequential compression stockings.
E) Explain that enoxaparin injections will be administered routinely.
Rationale:
B. 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 VTE in the legs.
C. Sequential compression devices (SCD) promote venous blood flow, preventing VTE.
E. 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: 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: 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 antiembolic 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: Unilateral calf edema.
