HESI Mobility questions and correct
answers
Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate
to severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should
the nurse draw up for administration? - ANSWER-1.6
Before giving the initial dose of pain medication or antibiotic, which action should the nurse take
first? - ANSWER-Ask the client if he is aware of any allergies to medications.
This action should be taken first since this is the initial dose of a new medication. It is important to
verify any allergies. Clients sometimes recall additional allergies after the initial admission history
has been taken.
When the client's foot pain is controlled, which nursing diagnosis should take priority ? - ANSWER-
Impaired physical mobility.
The client's limited activities support this nursing diagnosis. Improving mobility is a nursing priority
to prevent the many potential complications of immobility.
Which goal is correct for the client's diagnosis of impaired physical mobility? - ANSWER-The client
will sit in the chair for each meal beginning on the day of admission.
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 the client is to achieve and sets a realistic deadline.
Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the
client's legs? - ANSWER-Teach the client 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 VTE in the legs.
Instruct the client to wear sequential compression stockings.
Sequential compression devices (SCD) promote venous blood flow, preventing VTE.
Explain that enoxaparin injections will be administered routinely.
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.
Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible
clot dislodgment.
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.
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the
HCP.
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.
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.
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? - ANSWER-0.6
The client is 6 feet 2 inches tall and weighs 140 lbs (63.5 kg). The nurse calculates his Body Mass
Index (BMI) as 18. The nurse continues the nutritional assessment. the client's wife tells the nurse
that she cooks every day, but the client does not even eat his favorite foods anymore, although he
does drink a lot of diet colas.
Which nursing diagnosis best applies to the client'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.
The client 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 the client to increase his intake of which foods to prevent a decrease in bone
density? - ANSWER-Calcium rich foods.
Calcium must be deposited in the bone to increase bone density.
answers
Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate
to severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should
the nurse draw up for administration? - ANSWER-1.6
Before giving the initial dose of pain medication or antibiotic, which action should the nurse take
first? - ANSWER-Ask the client if he is aware of any allergies to medications.
This action should be taken first since this is the initial dose of a new medication. It is important to
verify any allergies. Clients sometimes recall additional allergies after the initial admission history
has been taken.
When the client's foot pain is controlled, which nursing diagnosis should take priority ? - ANSWER-
Impaired physical mobility.
The client's limited activities support this nursing diagnosis. Improving mobility is a nursing priority
to prevent the many potential complications of immobility.
Which goal is correct for the client's diagnosis of impaired physical mobility? - ANSWER-The client
will sit in the chair for each meal beginning on the day of admission.
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 the client is to achieve and sets a realistic deadline.
Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the
client's legs? - ANSWER-Teach the client 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 VTE in the legs.
Instruct the client to wear sequential compression stockings.
Sequential compression devices (SCD) promote venous blood flow, preventing VTE.
Explain that enoxaparin injections will be administered routinely.
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.
Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible
clot dislodgment.
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.
Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the
HCP.
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.
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.
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? - ANSWER-0.6
The client is 6 feet 2 inches tall and weighs 140 lbs (63.5 kg). The nurse calculates his Body Mass
Index (BMI) as 18. The nurse continues the nutritional assessment. the client's wife tells the nurse
that she cooks every day, but the client does not even eat his favorite foods anymore, although he
does drink a lot of diet colas.
Which nursing diagnosis best applies to the client'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.
The client 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 the client to increase his intake of which foods to prevent a decrease in bone
density? - ANSWER-Calcium rich foods.
Calcium must be deposited in the bone to increase bone density.
