Mobility HESI Case Study questions and
sure answers
Meet the Client - ANSWER-An older adult pt is treated in the ED for an infected wound on his R-foot.
The pt states he was walking barefoot & stepped on something sharp that cut his foot. He treated it
with topical antibiotics, but it appears red & inflamed, c̅ purulent drainage. The pt is admitted to the
med-surg unit for in-pt wound care tx & prescribed an antibiotic & pain med.
Section 1
Nursing Diagnosis - ANSWER-The pt states the pain level in his right foot is 8/10. He says he has been
favoring his foot by staying in bed the past week.
Before giving the initial dose of pain med or antibiotic, which action should the RN take first?
O Ask the client what liquid he would like to drink to swallow the pill.
O Teach the client the side effects of the medication.
O Ask the client if he is aware of any allergies to medications.
O Instruct the client to sit upright to swallow the medication. - ANSWER-Ask the client if he is aware
of any allergies to medications.
This takes priority because it is the initial dose of a new med.
#1 should still be taken, another action takes priority.
#2 is important, but doesn't have immediate priority.
#4 is important, but is the last step.
When the client's foot pain is controlled, which nursing problem should take priority?
O Risk for caregiver role strain.
O Risk for social isolation.
O Impaired physical mobility.
O Imbalanced nutrition: more than body requirements. - ANSWER-Impaired physical mobility.
The pt's limited activity support this. This is a nursing priority to prevent many complications.
#1 exists for pt's wife, not priority.
#2 can occur, but not the priority.
, #4 has no supporting evidence.
Which goal is correct for the client's problem of impaired physical mobility?
O The client will transfer to the chair with assist of one person.
O The nurse will reposition the client every hour while the client is awake.
O The client will sit in the chair for each meal beginning on the day of admission.
O The nurse will assist the client to ambulate in the hall by second hospital day. - ANSWER-The client
will sit in the chair for each meal beginning on the day of admission.
This is a pt goal: what pt is to achieve & sets a realistic deadline. Subject = pt; action = measurable.
#1 is an incomplete goal.
#2 is a nursing action, not a measurable goal.
#4 is a nursing action, not a pt goal.
Section 2
Prevention of Venous Thrombosis - ANSWER-The pt is reluctant to move in bed or to chair. He likes
spouse to place pillow beneath knee. The RN informs them that the PCP ordered enoxaparin
injsterm-4 & antiembolic stockings. The RN performs a focused PA, revealing diminished dorsalis
pedis pulses BIL.
Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the
client's legs?
Select all that apply.
O Encourage the client to use the incentive spirometer 10 times an hour while awake.
O Teach the client to dorsal flex and plantar flex his feet while in bed and chair.
O Instruct the client to wear sequential compression stockings.
O Advise the client to try not to move and cause pain in his foot wound.
O Explain that enoxaparin injections will be administered routinely. - ANSWER-- Teach the client to
dorsal flex and plantar flex his feet while in bed and chair.
- Instruct the client to wear sequential compression stockings.
- Explain that enoxaparin injections will be administered routinely.
#2 promotes circulation by contracting calf muscles, inc. venous return. Dec. blood pooling in legs.
sure answers
Meet the Client - ANSWER-An older adult pt is treated in the ED for an infected wound on his R-foot.
The pt states he was walking barefoot & stepped on something sharp that cut his foot. He treated it
with topical antibiotics, but it appears red & inflamed, c̅ purulent drainage. The pt is admitted to the
med-surg unit for in-pt wound care tx & prescribed an antibiotic & pain med.
Section 1
Nursing Diagnosis - ANSWER-The pt states the pain level in his right foot is 8/10. He says he has been
favoring his foot by staying in bed the past week.
Before giving the initial dose of pain med or antibiotic, which action should the RN take first?
O Ask the client what liquid he would like to drink to swallow the pill.
O Teach the client the side effects of the medication.
O Ask the client if he is aware of any allergies to medications.
O Instruct the client to sit upright to swallow the medication. - ANSWER-Ask the client if he is aware
of any allergies to medications.
This takes priority because it is the initial dose of a new med.
#1 should still be taken, another action takes priority.
#2 is important, but doesn't have immediate priority.
#4 is important, but is the last step.
When the client's foot pain is controlled, which nursing problem should take priority?
O Risk for caregiver role strain.
O Risk for social isolation.
O Impaired physical mobility.
O Imbalanced nutrition: more than body requirements. - ANSWER-Impaired physical mobility.
The pt's limited activity support this. This is a nursing priority to prevent many complications.
#1 exists for pt's wife, not priority.
#2 can occur, but not the priority.
, #4 has no supporting evidence.
Which goal is correct for the client's problem of impaired physical mobility?
O The client will transfer to the chair with assist of one person.
O The nurse will reposition the client every hour while the client is awake.
O The client will sit in the chair for each meal beginning on the day of admission.
O The nurse will assist the client to ambulate in the hall by second hospital day. - ANSWER-The client
will sit in the chair for each meal beginning on the day of admission.
This is a pt goal: what pt is to achieve & sets a realistic deadline. Subject = pt; action = measurable.
#1 is an incomplete goal.
#2 is a nursing action, not a measurable goal.
#4 is a nursing action, not a pt goal.
Section 2
Prevention of Venous Thrombosis - ANSWER-The pt is reluctant to move in bed or to chair. He likes
spouse to place pillow beneath knee. The RN informs them that the PCP ordered enoxaparin
injsterm-4 & antiembolic stockings. The RN performs a focused PA, revealing diminished dorsalis
pedis pulses BIL.
Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the
client's legs?
Select all that apply.
O Encourage the client to use the incentive spirometer 10 times an hour while awake.
O Teach the client to dorsal flex and plantar flex his feet while in bed and chair.
O Instruct the client to wear sequential compression stockings.
O Advise the client to try not to move and cause pain in his foot wound.
O Explain that enoxaparin injections will be administered routinely. - ANSWER-- Teach the client to
dorsal flex and plantar flex his feet while in bed and chair.
- Instruct the client to wear sequential compression stockings.
- Explain that enoxaparin injections will be administered routinely.
#2 promotes circulation by contracting calf muscles, inc. venous return. Dec. blood pooling in legs.
