The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion?

Correct Answer: B

Rationale: A former cigarette smoker is at increased risk for thrombus formation due to the damage smoking causes to the blood vessels, increasing the likelihood of blood clots. Smoking can also contribute to inflammation and increased platelet activation, further promoting clot formation. This risk factor is particularly concerning in a client undergoing a total hip replacement surgery, as immobility and surgery itself can also increase the risk of blood clots forming. Monitoring and addressing this risk factor is important in preventing potential complications such as deep vein thrombosis or pulmonary embolism in this client population. While the other assessment findings are important to consider for overall health, the former cigarette smoking status is specifically associated with thrombus formation in this scenario.

Correct Answer: C

Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.

Correct Answer: D

Rationale: Vomiting can lead to dehydration and electrolyte imbalances due to the loss of fluids and electrolytes. In response to these physiologic changes caused by vomiting, aldosterone secretion will increase. Aldosterone is a hormone produced by the adrenal glands that acts on the kidneys to increase reabsorption of sodium and water, helping to maintain blood pressure and electrolyte balance. By increasing aldosterone secretion, the body aims to retain more sodium and water to counteract the effects of vomiting and prevent dehydration.

Correct Answer: B

Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.

Correct Answer: B

Rationale: Given that the patient has a compound, open fracture of the femur and is undergoing immediate surgery, the most critical nursing diagnosis in the immediate postoperative period would be the risk for infection. Open fractures are particularly susceptible to infection due to the exposure of the fracture site to external contaminants. Postoperative care should prioritize infection prevention measures like sterile dressing changes, administration of prophylactic antibiotics, and close monitoring for signs of infection such as increased pain, redness, swelling, or drainage from the wound. Mitigating the risk of infection is crucial to prevent complications and promote optimal healing of the fracture. While the other diagnoses are relevant, addressing the risk for infection takes precedence in this scenario.