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Questions 148

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Question 1 of 5

The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:

Correct Answer: A

Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.

Question 2 of 5

The nurse has orders for dopamine at 20 mcg/kg/min. The bag has 500 mg of dopamine in 500 mL. The client weighs 60 kg. What rate will the nurse set?

Correct Answer: 72 mL/hr

Rationale: Dose: 20 mcg/kg/min × 60 kg = 1200 mcg/min. Concentration: 500 mg/500 mL = 1 mg/mL = 1000 mcg/mL. Rate: 1200 mcg/min ÷ 1000 mcg/mL = 1.2 mL/min × 60 min/hr = 72 mL/hr.

Question 3 of 5

The RN is making assignments for the day. Which one of the following duties can be assigned to the unlicensed assistive personnel?

Correct Answer: B

Rationale: Unlicensed assistive personnel can perform routine catheter care, a non-invasive task within their scope.

Question 4 of 5

A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means

Correct Answer: A

Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.

Question 5 of 5

A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

Correct Answer: A

Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.

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