A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?

Correct Answer: A

Rationale: The nurse should prioritize closely monitoring the input and output of the bladder irrigation system to assess for the risk of imbalanced fluid volume in a patient following a transuretheral resection of the prostate. Bladder irrigation is a common postoperative procedure used to prevent blood clots and help with healing. Monitoring the input and output of the bladder irrigation system is crucial in assessing the patient's fluid balance. Changes in the output may indicate bleeding or retention, which can lead to imbalanced fluid volume. By closely monitoring the bladder irrigation system, the nurse can promptly identify any issues and intervene accordingly to prevent further complications. Monitoring the patient's level of consciousness, skin turgor, and scanning for bladder retention are important assessments, but for this specific situation, monitoring the bladder irrigation system is the priority to assess for imbalanced fluid volume.

Correct Answer: A

Rationale: A person whose vision is measured at 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. In this measurement system, the first number represents how far away the person is from the eye chart (the testing distance), and the second number indicates how far away a person with normal vision can be from the chart to see the same line of letters or objects. Therefore, if someone has 20/40 vision, it means they need to be at 20 feet to see what a person with 20/20 vision can see at 40 feet.

Correct Answer: B

Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.

Correct Answer: D

Rationale: Blurred vision is a common adverse effect of pilocarpine, a miotic agent commonly used for open-angle glaucoma. It occurs due to the constriction of the pupil, which can affect the patient's ability to focus clearly. Therefore, it is important for the nurse to explain to the patient that blurred vision is an expected adverse effect of the medication. This reassurance can help alleviate the patient's concerns and improve their understanding of the medication therapy. Holding the next dose and notifying the physician is not necessary in this situation as blurred vision is a known side effect and treating the patient for an allergic reaction or suggesting that the patient put on her glasses would not address the underlying cause of the blurred vision.

Correct Answer: C

Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.