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 for Correct Answer (C): Asking the NAP to record the patient's vital signs before administering medications is the correct clinical decision. Vital signs are crucial indicators of a patient's health status and should be documented before any interventions. By having the NAP record the vital signs, the nurse ensures that the patient's condition is properly assessed and monitored. This action aligns with the standard of care and promotes patient safety.

Summary of Incorrect Choices:
A: Administering medications without knowing the patient's vital signs could be dangerous, especially if there are abnormalities that need attention.
B: Reviewing vital signs upon return delays necessary assessment and intervention, potentially compromising patient safety.
D: Omitting vital signs without assessment puts the patient at risk, as changes in vital signs can indicate underlying issues that need immediate attention.

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A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)

  • A. Equipment
  • B. Safe environment
  • C. Confidence
  • D. Assistive personnel
Correct Answer: A

Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.

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.

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: The correct answer is C. The nurse should ask the NAP to record the patient's vital signs before administering medications. This is important for ensuring patient safety and monitoring any potential changes in the patient's condition. By having the NAP record the vital signs, the nurse can assess the patient's current status and make informed decisions regarding medication administration.

Option A is incorrect because administering medications without knowing the patient's vital signs, especially if they are abnormal, can be risky. Option B is not the best choice as it delays addressing the missing vital signs. Option D is incorrect as omitting vital signs assessment is not in line with best practices for patient care.

The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?

  • A. Poor control of blood glucose levels
  • B. Current of recent foot trauma
  • C. Inappropriate foot care
  • D. Advanced age
Correct Answer: D

Rationale: Step 1: Define nonmodifiable risk factors - these are factors that cannot be changed or controlled by the individual.
Step 2: Advanced age is a nonmodifiable risk factor as it is determined by genetics and time.
Step 3: Poor control of blood glucose levels, foot trauma, and inappropriate foot care are modifiable risk factors that can be managed through lifestyle changes or medical interventions.
Summary: Choice D is correct because advanced age is a nonmodifiable risk factor for diabetes mellitus, while the other choices involve factors that can be modified through appropriate actions.

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.

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