ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

Review ADPIE Nursing Process Questions related questions and content

After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported

  • A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
  • B. review vital signs upon return.
  • C. Ask the NAP to record the patient’s vital signs before administering medications.
  • D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C

Rationale: Rationale:
1. Safety: Recording vital signs is crucial for patient safety.
2. Accountability: The nurse is ultimately responsible for ensuring vital signs are documented accurately.
3. Communication: It is essential for the nurse to communicate with the NAP to address the missed vital signs.
4. Corrective Action: Asking the NAP to record vital signs before administering medications ensures proper monitoring.
5. Patient-Centered Care: Prioritizing patient well-being by ensuring vital signs are up-to-date.

Summary:
A: Incorrect. Administering medications without vital sign assessment is unsafe.
B: Incorrect. Reviewing vital signs upon return does not address the immediate need for accurate documentation.
D: Incorrect. Omitting vital signs compromises patient safety and violates standard nursing practice.

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Which of the following client outcomes best describes the parameters for achieving the outcome?

  • A. The client will eat a well-balanced diet.
  • B. The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow.
  • C. The client will cleanse his wound with soap and water and apply a dry sterile dressing.
  • D. The client will be without pain in 24 hours.
Correct Answer: B

Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.

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.

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.

A patient’s chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse’s assessment most reflects these x-ray examination findings?

  • A. Fatigue
  • B. Peripheral edema
  • C. Bilateral crackles
  • D. Jugular vein distention
Correct Answer: C

Rationale: The correct answer is C, bilateral crackles. Fluid in both lung bases on x-ray indicates pulmonary edema, causing crackles on auscultation. Fatigue (A) is a nonspecific symptom. Peripheral edema (B) is a sign of fluid retention in the extremities, not lungs. Jugular vein distention (D) indicates increased central venous pressure, which is not specific to lung fluid.

Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?

  • A. Sore throat
  • B. Acute pain
  • C. Sleep apnea
  • D. Heart failure
Correct Answer: B

Rationale: The correct answer is B: Acute pain. The rationale is that NANDA-I (North American Nursing Diagnosis Association-International) approves nursing diagnoses that are specific, measurable, and relevant to nursing care. Acute pain fits these criteria as it is a common nursing diagnosis that can be assessed objectively and treated with nursing interventions. The other choices (sore throat, sleep apnea, heart failure) are medical diagnoses that do not fall under the scope of nursing diagnoses approved by NANDA-I. Therefore, acute pain is the most appropriate diagnosis to be documented in a patient's care plan according to NANDA-I guidelines.

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