ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

Review ADPIE Nursing Process Questions related questions and content

A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?

  • A. Subjective data
  • B. Objective data
  • C. Secondary data
  • D. Primary data
Correct Answer: B

Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data.

Summary:
- A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse.
- C: Secondary data are information obtained from other sources, not directly from the client.
- D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.

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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?

  • A. Avoiding using a soap on the irradiated areas
  • B. Applying talcum powder to the irradiated areas daily after bathing
  • C. Wearing a lead apron during direct contact with the client
  • D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A

Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. This is because soap can irritate the skin, leading to skin breakdown in a client at risk for impaired skin integrity due to radiation therapy. Avoiding soap helps to prevent further damage to the skin.

Choice B is incorrect as talcum powder can further irritate the skin and should be avoided. Choice C is not relevant to preventing skin integrity issues. Choice D is incorrect because thoracic skin markings should not be removed as they are essential for accurate radiation delivery.

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?

  • A. Consult physical therapy.
  • B. Establish a new plan of care.
  • C. Set new priorities for the patient.
  • D. Assess the patient.
Correct Answer: D

Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.

What is the best way to detect testicular cancer early?

  • A. Monthly testicular self-examination
  • B. Annual physician examination
  • C. Yearly digital rectal examination
  • D. Annual ultrasonography
Correct Answer: A

Rationale: The correct answer is A: Monthly testicular self-examination. This is the best way to detect testicular cancer early because it allows individuals to become familiar with the normal size, shape, and texture of their testicles, making it easier to notice any changes or abnormalities. Self-examination is cost-effective, convenient, and can be done regularly to monitor for any signs of cancer. Annual physician examination (B) may not be frequent enough for early detection. Yearly digital rectal examination (C) is not relevant for detecting testicular cancer. Annual ultrasonography (D) is not recommended as a routine screening tool for testicular cancer.

The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

  • A. Use commercial preparations to remove
  • B. Wash and inspect the feet daily
  • C. Walk barefoot at least once each daily
  • D. Cut the toenails by rounding edges
Correct Answer: B

Rationale: The correct answer is B: Wash and inspect the feet daily. This is important for clients with diabetes mellitus to prevent complications like foot ulcers. Daily foot care helps detect any issues early. Choice A is incorrect as it is not recommended to use commercial preparations without medical advice. Choice C is incorrect as walking barefoot can increase the risk of injury and infection. Choice D is incorrect as cutting toenails by rounding edges can lead to ingrown toenails, which can be dangerous for clients with diabetes.

Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?

  • A. Pain when talking
  • B. Increased nasal swelling
  • C. Burning in the throat
  • D. Presence of laryngospasm INFECTIONS OF THE LOWER RESPIRATORY AIRWAY
Correct Answer: D

Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.

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