ADPIE Nursing Process Questions

Correct Answer: D

Rationale: The correct answer is D: hypoglycemia. In a diabetic patient, signs of irritability, irrational behavior, and visible tremors in the hands indicate low blood sugar levels, which is hypoglycemia. This is because the brain relies on glucose for energy, and when blood sugar levels drop too low, it can lead to neuroglycopenic symptoms such as confusion and tremors. Explanation for why the other choices are incorrect: A: hyperglycemia - High blood sugar levels typically present with symptoms such as frequent urination, increased thirst, and fatigue, not irritability and tremors. B: hyperglycemic hyperosmolar - This condition is characterized by extremely high blood sugar levels and severe dehydration, leading to symptoms such as extreme thirst and confusion, not irritability and tremors. C: diabetic ketoacidosis (DKA) nonketosis (HHNK) - These conditions are associated with high blood sugar levels and metabolic disturbances,

Correct Answer: C

Rationale: The correct answer is C, the 35-year-old with kidney failure. Patients with kidney failure are at high risk for fluid volume overload due to the kidneys' inability to properly regulate fluid balance. This can lead to accumulation of excess fluids in the body, causing edema, hypertension, and heart failure. In contrast, choices A, B, and D are not at as high risk for fluid volume overload as patients with kidney failure, as their conditions do not directly impact fluid regulation in the body.

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.

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.

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.