ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

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The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?

  • A. “Yes, all pregnant women must have the test.”
  • B. “If you do not have multiple sex partners or inject drugs, it is not necessary.”
  • C. “Governmental guidelines require an HIV test for all pregnant woman.”
  • D. “After voluntary pretest counseling, you decide whether HIV testing should be done.”
Correct Answer: A

Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.

Summary of Incorrect Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.

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Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?

  • A. Restrict fluid intake
  • B. Ensure that the client avoids prolonged sitting
  • C. Position lower extremities below level of heart
  • D. Instruct the client to avoid leg exercises
Correct Answer: C

Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery.

A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion.
B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion.
D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.

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.

Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?

  • A. Hyperventilating James with 100% oxygen before and after suctioning
  • B. Instilling 3 to 5 ml normal saline to loosen up secretion
  • C. Applying suction during catheter withdrawal
  • D. Suction the client every hour
Correct Answer: A

Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.

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.

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