ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

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An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?

  • A. Risk for increased cardiac output related to fluid volume excess
  • B. Disturbed sensory perception related to bleeding into tissues
  • C. Alteration in tissue perfusion related to bleeding and diminished blood flow
  • D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C

Rationale: The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.

Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.

In summary, the correct answer is C because DIC can lead to altered tissue perfusion

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The nurse would expect which of the following would be included in the plan of care/

  • A. Have the client drink at least 8 glases of water in the first day
  • B. Administer NaHCO3 IV as per physician’s orders
  • C. Continue sodium bicarbonate for nausea
  • D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D

Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia.
Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness.
Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects.
Summary:
A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate.
B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders.
C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.

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. This is the only choice that aligns with NANDA-I approved nursing diagnoses. Acute pain is a common nursing diagnosis that focuses on addressing a patient's immediate discomfort. NANDA-I emphasizes the importance of using standardized nursing diagnoses to improve communication and ensure proper interventions. Sore throat (A) and sleep apnea (C) are symptoms or medical diagnoses, not specific nursing diagnoses. Heart failure (D) is a medical diagnosis and not a NANDA-I approved nursing diagnosis.

A febrile patient’s fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:

  • A. 300ml/24hr
  • B. 900ml/24hr
  • C. 600ml/24hr
  • D. 1200ml/24hr
Correct Answer: C

Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.

Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?

  • A. dextrose
  • B. electrolytes
  • C. trace minerals
  • D. amino acids
Correct Answer: C

Rationale: The correct answer is C: trace minerals. TPN solutions typically include dextrose for energy, electrolytes for maintaining fluid balance, and amino acids for protein synthesis. Trace minerals are not typically included in TPN solutions as they are only required in small amounts and can be toxic in excess. Therefore, it is not likely to be in the solution. The other choices (A, B, D) are essential components of TPN solutions necessary for meeting the nutritional needs of the patient.

Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:

  • A. 48 hours
  • B. 2 hours
  • C. 12 hours
  • D. 24 hours
Correct Answer: D

Rationale: The correct answer is D: 24 hours. Compartment syndrome occurs when pressure within a closed muscle compartment increases, leading to decreased circulation and potential tissue damage. Monitoring is crucial as irreversible damage can occur if left untreated. The 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, pressure) are key indicators. Waiting for 48 hours (choice A) or 12 hours (choice C) is too long and can result in severe consequences. 2 hours (choice B) is too short a timeframe to assess for irreversible damage development, making 24 hours (choice D) the most appropriate timeframe for monitoring and intervention.

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