HESI Case Study: Mobility
Study online at https://quizlet.com/_dw5m4o
1. Client was prescribed morphine IV 140 lb /2.2 lb = 63 kg
0.05mg/kg/dose now and every 2 hours as 63 kg x 0.05 mg = 3.15 mg
needed for moderate to severe pain. Mor- 3.15 mg / 2 ml = 1.575 ml
phine is available in parenteral dose of 1.575 ml (Round) = 1.6 ml
2mg/mL. How much medication should the
nurse draw up for administration? (Patient
weighs 140 lbs on admission).
2. Before giving the initial dose of pain med- C) Ask the client if he is aware of any
ication or antibiotic, which action should the allergies to medications.
nurse take first?
Rationale:
This action should be taken first since
this is the initial dose of a new medica-
tion. It is important to verify any aller-
gies. Clients sometimes recall additional
allergies after the initial admission his-
tory has been taken.
3. When the client's foot pain is controlled, C) Impaired physical mobility.
which nursing diagnosis should take priority?
Rationale:
The client's limited activities support this
nursing diagnosis. Improving mobility is
a nursing priority to prevent the many
potential complications of immobility.
4. Which goal is correct for the client's diagnosis C) The client will sit in the chair for each
of impaired physical mobility? meal beginning on the day of admis-
sion.
Rationale:
This is a correctly stated goal. The client
1/8
, HESI Case Study: Mobility
Study online at https://quizlet.com/_dw5m4o
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.
5. Which instructions should the nurse convey B) Teach the client to dorsal flex and
to help prevent venous thromboembolism plantar flex his feet while in the bed and
(VTE) in the client's legs? (Select all that apply. chair.
One, some, or all options may be correct.) C) Instruct the client to wear sequential
compression stockings.
E) Explain that enoxaparin injections will
be administered routinely.
Rationale:
This action stimulates circulation by con-
tracting calf muscles, which increases
the venous return of blood to the heart.
These decreases pooling of blood in
the legs, which helps VTE in the legs.
Sequential compression devices (SCD)
promote venous blood flow, preventing
VTE. Enoxaparin is an anticoagulant that
is administered to reduce the risk of VTE.
6. The nurse is observing a student nurse per- C) Assessing the Homan's sign in bilat-
form a peripheral assessment on the client. eral extremities.
Which action requires the nurse to intervene?
Rationale:
Homan's sign is "not a reliable indi-
cator" and is a potentially dangerous
method because of possible clot dis-
lodgment.
2/8
Study online at https://quizlet.com/_dw5m4o
1. Client was prescribed morphine IV 140 lb /2.2 lb = 63 kg
0.05mg/kg/dose now and every 2 hours as 63 kg x 0.05 mg = 3.15 mg
needed for moderate to severe pain. Mor- 3.15 mg / 2 ml = 1.575 ml
phine is available in parenteral dose of 1.575 ml (Round) = 1.6 ml
2mg/mL. How much medication should the
nurse draw up for administration? (Patient
weighs 140 lbs on admission).
2. Before giving the initial dose of pain med- C) Ask the client if he is aware of any
ication or antibiotic, which action should the allergies to medications.
nurse take first?
Rationale:
This action should be taken first since
this is the initial dose of a new medica-
tion. It is important to verify any aller-
gies. Clients sometimes recall additional
allergies after the initial admission his-
tory has been taken.
3. When the client's foot pain is controlled, C) Impaired physical mobility.
which nursing diagnosis should take priority?
Rationale:
The client's limited activities support this
nursing diagnosis. Improving mobility is
a nursing priority to prevent the many
potential complications of immobility.
4. Which goal is correct for the client's diagnosis C) The client will sit in the chair for each
of impaired physical mobility? meal beginning on the day of admis-
sion.
Rationale:
This is a correctly stated goal. The client
1/8
, HESI Case Study: Mobility
Study online at https://quizlet.com/_dw5m4o
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.
5. Which instructions should the nurse convey B) Teach the client to dorsal flex and
to help prevent venous thromboembolism plantar flex his feet while in the bed and
(VTE) in the client's legs? (Select all that apply. chair.
One, some, or all options may be correct.) C) Instruct the client to wear sequential
compression stockings.
E) Explain that enoxaparin injections will
be administered routinely.
Rationale:
This action stimulates circulation by con-
tracting calf muscles, which increases
the venous return of blood to the heart.
These decreases pooling of blood in
the legs, which helps VTE in the legs.
Sequential compression devices (SCD)
promote venous blood flow, preventing
VTE. Enoxaparin is an anticoagulant that
is administered to reduce the risk of VTE.
6. The nurse is observing a student nurse per- C) Assessing the Homan's sign in bilat-
form a peripheral assessment on the client. eral extremities.
Which action requires the nurse to intervene?
Rationale:
Homan's sign is "not a reliable indi-
cator" and is a potentially dangerous
method because of possible clot dis-
lodgment.
2/8
