ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

Review ADPIE Nursing Process Questions related questions and content

A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.)

  • A. Observations of wound healing
  • B. Daily blood pressure measurements
  • C. Findings of respiratory rate and depth
  • D. Completion of nursing interventions NursingStoreRN
Correct Answer: A

Rationale: The correct answer is A: Observations of wound healing. This is the correct evaluative measure because it directly assesses the patient's response to nursing care, indicating the effectiveness of interventions. Wound healing is a tangible and visible indicator of the patient's overall health status and the success of nursing interventions.

The other choices are incorrect:
B: Daily blood pressure measurements do not solely indicate a patient's response to nursing care. Blood pressure can be affected by various factors unrelated to nursing interventions.
C: Findings of respiratory rate and depth are important for assessing respiratory status but may not directly reflect the patient's response to nursing care.
D: Completion of nursing interventions is a process measure and does not provide direct insight into the patient's response to care.

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An adult is being taught about a healthy diet. How can the food pyramid help guide the client on his diet?

  • A. By indicating exactly how many servings of each group to eat
  • B. By calculating how many calories the client should have
  • C. By suggesting daily food choices
  • D. By dividing the food into four basic groups
Correct Answer: C

Rationale: The correct answer is C: By suggesting daily food choices. The food pyramid helps guide a client's diet by recommending the types and proportions of food to consume daily, such as fruits, vegetables, grains, protein, and dairy. It does not specify exact servings (A), calculate calories (B), or divide food into only four basic groups (D). The pyramid is a visual representation of a balanced diet, emphasizing variety and moderation.

When taking the blood pressure of a client who has AIDS the nurse must;

  • A. Wear a mask and gown
  • B. Use barrier techniques
  • C. Wash the hands thoroughly
Correct Answer: B

Rationale: The correct answer is B: Use barrier techniques. When taking the blood pressure of a client with AIDS, using barrier techniques such as gloves and disposable equipment is crucial to prevent the transmission of the virus through blood or bodily fluids. Wearing a mask and gown (choice A) may not be necessary unless there is a risk of splashes or sprays. Washing hands thoroughly (choice C) is important, but alone may not provide sufficient protection. Choice D is incomplete.

A client who was diagnosed with type I diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client’s blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

  • A. Cool, moist skin
  • B. Arm and leg trembling
  • C. Rapid, thready pulse
  • D. Slow, shallow respirations
Correct Answer: B

Rationale: The correct answer is B: Arm and leg trembling. With a blood glucose level of 470 mg/dl in a client with type I diabetes mellitus, the most likely finding is arm and leg trembling, which is a common symptom of hypoglycemia. This occurs due to the body's response to low blood sugar levels, causing tremors as a compensatory mechanism to increase glucose utilization. The other choices are incorrect because cool, moist skin is a sign of hypoglycemia, rapid thready pulse is a sign of shock or hypovolemia, and slow shallow respirations are not typically associated with high blood glucose levels in this scenario.

The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

  • A. Sodium level of 140 mEq/l.
  • B. Direct bilirubin level of 2 mg/dl
  • C. Prothrombin time of 12 seconds
  • D. Platelet count of 400,000/mm3
Correct Answer: B

Rationale: The correct answer is B: Direct bilirubin level of 2 mg/dl. Acetaminophen toxicity can lead to liver damage, causing an increase in bilirubin levels. Direct bilirubin specifically indicates liver function. A: Sodium level is not related to acetaminophen toxicity. C: Prothrombin time is a measure of blood clotting, not indicative of acetaminophen toxicity. D: Platelet count is not affected by acetaminophen toxicity.

During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:

  • A. Enzyme-linked immunosuppressant assay
  • B. Stool for Clostridium difficile test
  • C. Flat palate X-ray of the abdomen
  • D. Electrolyte panel and hemogram
Correct Answer: B

Rationale: The correct answer is B: Stool for Clostridium difficile test. In this scenario, the client is experiencing symptoms suggestive of a possible Clostridium difficile infection, a common complication of chemotherapy. The test is crucial to confirm the presence of C. difficile toxins in the stool, which would guide appropriate treatment with antibiotics such as metronidazole or vancomycin.

A: Enzyme-linked immunosuppressant assay is not relevant in this context as it is used to measure levels of immunosuppressant drugs, not for diagnosing C. difficile infection.
C: Flat palate X-ray of the abdomen is unnecessary and would not provide information about the cause of the symptoms.
D: Electrolyte panel and hemogram are important for monitoring overall health status but do not directly address the specific issue of possible C. difficile infection.

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