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: Step 1: Safety First - The nurse's priority is patient safety. Without vital signs, medication administration can be unsafe.
Step 2: Accountability - The nurse must ensure accurate and timely vital signs recording before making clinical decisions.
Step 3: Delegation - Asking the NAP to record vital signs aligns with their role and helps maintain a reliable record.
Step 4: Proactive Approach - By having the NAP record vital signs, the nurse can make informed decisions based on accurate data.

Summary:
A: Incorrect - Proceeding with medications without vital signs can risk patient safety.
B: Incorrect - Waiting to review vital signs later can delay necessary interventions.
D: Incorrect - Omitting vital signs is negligent and compromises patient care.

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Why does the nurse instruct the client to avoid Valsalva maneuvers?

  • A. Clients BP will decrease momentarily
  • B. Client may lose consciousness
  • C. Client may suffer from a myocardial
  • D. Clients BP will increase momentarily infarction
Correct Answer: B

Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.

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.

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. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.

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.

A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?

  • A. “Anemia prevents your lungs from absorbing oxygen effectively.”
  • B. “You do not have enough hemoglobin to carry oxygen to your tissues.”
  • C. “”You don’t have enough blood to feed your cells.”
  • D. “You have lost a lot of blood, and that has damaged your lungs.”
Correct Answer: B

Rationale: The correct answer is B because hemoglobin carries oxygen to the tissues, and with a low hemoglobin level of 6 g/dL, there is insufficient oxygen-carrying capacity to meet the body's needs, leading to shortness of breath (SOB). Choice A is incorrect as anemia affects oxygen transport, not absorption. Choice C is incorrect as anemia affects oxygen delivery, not nutrient delivery. Choice D is incorrect as the primary reason for SOB in this scenario is the lack of oxygen-carrying capacity due to low hemoglobin levels, not lung damage from blood loss.

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