A patient is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag?

Correct Answer: A

Rationale: The correct answer is A: Red wine colored. Following a prostatectomy, continuous bladder irrigation is commonly used to prevent blood clots and ensure urine drainage. The output is expected to be red wine colored, indicating the presence of blood in the urine due to surgical trauma. Tea-colored (choice B) or amber (choice C) are not specific enough and do not accurately reflect the expected bloody output. Light pink (choice D) may suggest a lower level of bleeding compared to red wine color, but it is not the most accurate description for post-prostatectomy drainage.

Correct Answer: B

Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.

Correct Answer: A

Rationale: The correct answer is A: Continuous inflow and outflow of irrigation solution. The first lumen inflates the balloon to secure the catheter in place. The second lumen allows continuous inflow of irrigation solution to prevent clot formation. The third lumen allows continuous outflow to ensure the bladder is continuously irrigated. Choices B, C, and D are incorrect because they do not accurately describe the functions of the three lumens in a transurethral resection of the prostate procedure.

Correct Answer: B

Rationale: The correct answer is B: missed. In a missed abortion, the fetus dies but is not immediately expelled from the uterus. This term specifically describes the situation where the fetus is retained in the uterus. Choice A (inevitable) refers to a situation where abortion is certain to occur, choice C (incomplete) refers to partial expulsion of the fetus, and choice D (threatened) refers to a situation where the woman has vaginal bleeding, but the fetus is still viable. Therefore, the term "missed" accurately describes the scenario where the fetus dies but remains in the uterus.

Correct Answer: A

Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.

Correct Answer: C

Rationale: The correct answer is C: Avoid feminine hygiene products, such as sprays. This is because feminine hygiene products can disrupt the natural balance of vaginal flora, leading to an increased risk of vaginal infections. Tight-fitting synthetic underwear (choice A) can trap moisture and promote bacterial growth. Using bubble bath (choice B) can irritate the genital area and disrupt the pH balance. Restricting daily bathing (choice D) is not recommended as regular hygiene practices are important for preventing infections. In summary, choice C is correct as it promotes maintaining the natural vaginal flora and pH balance to prevent infections, while the other choices can contribute to an increased risk of vaginal infections.

Correct Answer: B

Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.

Correct Answer: A

Rationale: The correct answer is A: Accessibility of health care services. The nurse is monitoring disparities in access to healthcare services among different population groups. This is important as it can influence health outcomes and the prevalence of complications. Outcomes of health conditions (B) are impacted by access to care. Prevalence of complications (C) and incidence of diseases (D) can also be influenced by disparities in accessing healthcare services. However, the primary focus of the nurse's assessment in this scenario is on the accessibility of healthcare services as a key factor contributing to health care disparities.

Correct Answer: A

Rationale: The correct answer is A: When the patient is resting. This is because the tremor associated with Parkinson's disease is most noticeable when the patient is at rest due to the characteristic "resting tremor" seen in this condition. The tremor tends to lessen or disappear with purposeful movements or activities, making it more difficult to assess during ambulation, meal preparation, or occupational therapy. By observing the patient at rest, the nurse can accurately assess the presence and severity of the tremor, which is a key diagnostic feature of Parkinson's disease. Other answer choices are incorrect because they do not provide the optimal condition for assessing the tremor associated with Parkinson's disease.