Case Study: Mobility Hesi Midterm Exam Questions And Already Passed Answers.
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Course
Mobility hesi
Institution
Mobility Hesi
Patient Information - Answer An older adult client is treated in the emergency department (ED) for an infected wound on his right foot. The client states he was walking barefoot and stepped on something sharp that cut his foot. He treated it with topical antibiotics, but it appears red and infla...
Case Study: Mobility Hesi Midterm Exam
Questions And Already Passed Answers.
Patient Information - Answer An older adult client is treated in the emergency department (ED) for an
infected wound on his right foot. The client states he was walking barefoot and stepped on something
sharp that cut his foot. He treated it with topical antibiotics, but it appears red and inflamed, with
purulent drainage. The client is admitted to the medical-surgical unit for inpatient wound care treatment
and prescribed an antibiotic and pain medication.
Nursing Diagnosis - Answer Nursing DiagnosisThe client states the pain level in his right foot is 8 on a
scale of 1 to 10. He says he has been favoring his foot by staying in bed the past week.
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? (Patient weighs 140 lbs on admission). - Answer 140 lb /2.2 lb = 63
kg
63 kg x 0.05 mg = 3.15 mg
3.15 mg / 2 ml = 1.575 ml
1.575 ml (Round) = 1.6 ml
Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first? -
Answer C) Ask the client if he is aware of any allergies to medications.
Rationale:
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 C)
Impaired physical mobility.
Rationale:
, 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 C) The client will
sit in the chair for each meal beginning on the day of admission.
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 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? (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:
This action stimulates circulation by contracting 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.
The nurse is observing a student nurse perform a peripheral assessment on the client. Which action
requires the nurse to intervene? - Answer C) 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 A) Use two pillows and place one lengthwise under each calf.
Rationale:
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