ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

Review ADPIE Nursing Process Questions related questions and content

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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The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient’s gastrointestinal tract is resuming normal function?

  • A. Firm abdomen
  • B. Presence of flatus
  • C. Excessive thirst
  • D. Absent bowel sounds
Correct Answer: B

Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

  • A. Protocols are guidelines to follow that replace the nursing care plan. Protocols assist the clinician in making decisions and choosing interventions for specific
  • B. health care problems or conditions. Protocols are policies designating each nurse’s duty according to standards of care and a
  • C. code of ethics.
  • D. Protocols are prescriptive order forms that help individualize the plan of care.
Correct Answer: A

Rationale: The correct answer is A because protocols are indeed guidelines that assist clinicians in decision-making and choosing interventions for specific health care problems. This definition accurately reflects the purpose and function of protocols in nursing practice.

Option B is incorrect as it describes protocols as policies related to nurses' duties and standards of care, which is more aligned with job descriptions and policies rather than protocols.

Option C is incorrect as it relates protocols to a code of ethics, which is a separate concept that guides ethical decision-making and behavior in nursing practice.

Option D is incorrect as it inaccurately describes protocols as prescriptive order forms, which are actually separate from protocols and are used for medication administration and treatment orders.

Marichu is admitted to the hospital because of hepatic failure and was prescribed with lactulose (Duphalac). The primary action of this drug is:

  • A. prevent constipation
  • B. decrease resident intestinal flora
  • C. increase intestinal peristalsis
  • D. prevent portal hypertension
Correct Answer: B

Rationale: The correct answer is B: decrease resident intestinal flora. Lactulose is a synthetic sugar that is not absorbed in the intestine and is used to decrease ammonia levels in patients with hepatic encephalopathy by promoting the growth of beneficial gut bacteria that help metabolize ammonia. This action helps reduce the toxic effects of ammonia on the brain.

A: prevent constipation - Lactulose may help with constipation, but its primary action in this scenario is to decrease resident intestinal flora.
C: increase intestinal peristalsis - Lactulose does not directly increase peristalsis.
D: prevent portal hypertension - Lactulose does not have a direct effect on preventing portal hypertension.

To combat the most common adverse effects of chemotherapy, the nurse would administer an:

  • A. Antiemetic
  • B. Antibiotic
  • C. Antimetabolite
  • D. Anticoagulant
Correct Answer: A

Rationale: The correct answer is A: Antiemetic. Chemotherapy commonly causes nausea and vomiting as adverse effects. Antiemetics are medications specifically designed to prevent or alleviate nausea and vomiting. Administering an antiemetic helps manage these side effects and improve the patient's quality of life during chemotherapy. Antibiotics (B) are used to treat bacterial infections, not chemotherapy side effects. Antimetabolites (C) are a type of chemotherapy drug, not used to combat its side effects. Anticoagulants (D) are used to prevent blood clots and are not indicated for managing chemotherapy side effects like nausea and vomiting.

Which part of the brain controls breathing?

  • A. Medulla
  • B. Cerebrum
  • C. Cerebellum
  • D. Thalamus
Correct Answer: A

Rationale: The correct answer is A: Medulla. The medulla is located in the brainstem and plays a crucial role in controlling involuntary functions like breathing. It contains the respiratory center, which regulates the rate and depth of breathing. The medulla sends signals to the diaphragm and intercostal muscles to control breathing. The cerebrum (B) is responsible for higher brain functions, not breathing control. The cerebellum (C) coordinates movement and balance, not breathing. The thalamus (D) relays sensory information to the cerebral cortex, not involved in breathing regulation.

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