The nurse reviews a preoperative note for a 68-year-old client who is scheduled to have a right anterior Total Hip Arthroplasty (THA). The client has a history of several surgeries including hysterectomy, appendectomy, and cholecystectomy. The client has a 52-pack-year smoking history but quit 2 years ago, a BMI of 30.1, and a history of two deep vein thromboses (DVT). The client also has hypertension controlled by diet and drug therapy, high cholesterol controlled by statins, and GERD controlled by an antacid PRN.
Which assessment findings place the client at risk for a venous thromboembolism (VTE)? Select all that apply.
History of two previous deep vein thrombosis.
History of hypertension.
History of cholecystectomy.
Having a Total Hip Arthroplasty.
BMI of 30.1.
History of high cholesterol.
52-pack-year history.
Correct Answer : A,D,E,G
The scenario requires evaluating surgical and medical history to identify specific factors that increase the probability of clot formation. Knowledge of Virchow's triad, involving venous stasis, endothelial injury, and hypercoagulability, is applied to differentiate between general health issues and specific VTE risks.
Choice A rationale
A history of previous deep vein thrombosis is one of the strongest predictors for future occurrences. Past events indicate a predisposition to hypercoagulability or existing vascular damage, which significantly increases the risk during periods of surgical immobilization.
Choice B rationale
While hypertension is a significant cardiovascular risk factor for stroke or myocardial infarction, it is not traditionally categorized as a direct independent trigger for venous thromboembolism. It affects the high-pressure arterial system rather than the venous system.
Choice C rationale
Remote surgical history like a cholecystectomy does not present an active risk for a current procedure. Only the immediate perioperative period of the current surgery or a very recent surgery within thirty days contributes to VTE risk.
Choice D rationale
Major orthopedic surgeries, specifically total hip arthroplasties, carry an extremely high risk for VTE due to extensive local tissue trauma and prolonged venous stasis. These procedures require aggressive prophylaxis because they often cause direct venous endothelial injury.
Choice E rationale
A Body Mass Index of 30.1 indicates obesity, which increases intra-abdominal pressure and slows venous return from the lower extremities. This venous stasis, combined with chronic systemic inflammation associated with adipose tissue, raises the risk of clot formation.
Choice F rationale
High cholesterol, or hyperlipidemia, is a primary driver for atherosclerosis within the arterial system. While it impacts overall vascular health, it is not a primary or direct risk factor for developing venous thromboembolism in the perioperative setting.
Choice G rationale
Smoking causes significant endothelial dysfunction and increases blood viscosity, even if the client quit two years ago. The long-term damage to the vascular lining and chronic changes in coagulation factors contribute to an elevated risk profile.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This scenario requires understanding neurovascular pathophysiology following head trauma. Knowledge of early versus late signs of intracranial pressure is essential to identify neurological deterioration and prevent brain herniation. Clinical assessment focuses on mental status changes and autonomic vital sign stability.
Choice A rationale
Tachycardia is typically not a sign of increased intracranial pressure. Instead, Cushing triad occurs as a late sign, characterized by bradycardia, widened pulse pressure, and irregular respirations as the brainstem undergoes significant compression and ischemia.
Choice B rationale
Amnesia is a common finding following traumatic brain injury due to localized tissue damage or concussion. However, it is a static deficit rather than a dynamic indicator of rising pressure within the rigid cranial vault.
Choice C rationale
Hypotension is not an indicator of increased intracranial pressure. In the Cushing response, the body increases systolic blood pressure to maintain cerebral perfusion pressure against the rising resistance of the swelling brain tissue and cerebrospinal fluid.
Choice D rationale
Restlessness is an early sign of increased intracranial pressure resulting from decreased cerebral oxygenation. As pressure rises, the brain becomes hypoxic, leading to agitation, irritability, and decreased level of consciousness before more severe physical signs manifest.
Correct Answer is A
Explanation
Acute neurological deficits following a stroke increase the risk of secondary complications. Knowledge of cranial nerve involvement and protective reflexes is vital. The nurse must prioritize airway and respiratory safety within the critical 24 hour post ischemic event window.
Choice A rationale
Right sided weakness often includes the facial and pharyngeal muscles, impairing the gag reflex and swallowing. This increases the risk of food or secretions entering the lungs, leading to pneumonia or acute respiratory distress during recovery.
Choice B rationale
While urinary retention can occur after a stroke due to neurogenic bladder or immobility, it is not an immediate life threat. It requires monitoring and management but takes lower priority than ensuring the client maintains a patent airway.
Choice C rationale
Contractures are a long term complication of immobility and muscle spasticity following a stroke. While range of motion exercises are important for rehabilitation, they are not a priority during the first 24 hours of acute stabilization.
Choice D rationale
Depression is a common psychological consequence of the lifestyle changes and deficits caused by a stroke. However, psychological assessment occurs later in the care plan after the client is physiologically stable and out of danger.
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