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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Monitoring traumatic brain injury involves assessing neurological changes that indicate secondary brain injury. Knowledge of intracranial dynamics and Cushing's triad is essential to identify shifting brain tissue or worsening herniation, which requires immediate medical or surgical intervention to save life.

Choice A rationale

Pupillary changes indicate pressure on the oculomotor nerve but may occur earlier than profound neurological collapse. While important, they are often secondary indicators compared to the global decline seen in mental status and motor function.

Choice B rationale

Fever and elevated blood pressure can occur in brain injury due to hypothalamic dysfunction or sympathetic surges. However, without bradycardia and irregular respirations, they do not definitively indicate immediate, late-stage intracranial pressure emergencies.

Choice C rationale

Headache and nausea are subjective, early signs of increased intracranial pressure. While concerning and requiring monitoring, they do not signify the urgent physiological crisis or neurological deficit represented by a plummeting level of consciousness.

Choice D rationale

A decreased level of consciousness is the most sensitive indicator of neurological deterioration. Coupled with one-sided weakness, it suggests focal deficits or impending herniation, necessitating immediate reporting to prevent permanent brain damage or death.

A. Different blood pressures in the upper limbs. B. Differences in upper and lower lung sounds. C. Different apical and radial pulses. D. Differences between oral and axillary temperatures.

Correct Answer is C

Explanation

Identifying cardiac arrhythmias requires understanding the relationship between electrical conduction and mechanical output. Knowledge of pulse deficits is necessary to recognize when rapid, irregular atrial contractions fail to produce adequate ventricular filling and a palpable peripheral pulse.

Choice A rationale

Blood pressure discrepancies between the upper limbs usually indicate vascular issues like aortic dissection or peripheral arterial disease. Atrial fibrillation affects the rhythm and volume of the pulse rather than creating localized pressure differences between the arms.

Choice B rationale

Variations in lung sounds typically suggest localized pulmonary pathology such as pneumonia or pleural effusion. While atrial fibrillation can lead to heart failure and pulmonary edema, it does not specifically cause differences between upper and lower sounds.

Choice C rationale

A pulse deficit occurs when the apical heart rate is higher than the radial rate. In atrial fibrillation, some ventricular contractions are too weak to perfuse to the periphery, making this a classic assessment finding.

Choice D rationale

Discrepancies between oral and axillary temperatures relate to thermoregulation and measurement accuracy rather than cardiac rhythm. Temperature monitoring is used to screen for infection or inflammation but does not provide diagnostic information regarding atrial arrhythmias..

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Naxlex Comprehensive Predictor Exams

A client who sustained a severe traumatic brain injury is being monitored for signs of increased intracranial pressure (ICP). Which findings should the nurse report immediately to the healthcare provider?

Correct Answer is D

Explanation

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Correct Answer is C

Explanation

A client is admitted with urolithiasis and reports severe flank pain rated 9/10 with nausea and vomiting. The client has not voided in 6 hours. Which nursing action is the priority?

A client presents with severe hyperkalemia and cardiac arrhythmias. Which interventions are urgent to prevent life-threatening complications? Select all that apply.

The nurse tells the unlicensed assistive personnel to assist the client who is 1-day postoperative spinal surgery with a.m. care. Which action by the unlicensed assistive personnel warrants immediate intervention?

A client with a pulmonary embolism develops signs of severe hemoptysis and hypotension. What should be the nurse's immediate priority?

A client with end-stage cirrhosis and hepatic encephalopathy becomes increasingly confused and drowsy. Which intervention should the nurse implement to reduce ammonia levels?

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