ADPIE Nursing Process Questions

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.

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.

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.

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.

Correct Answer: A

Rationale: The correct answer is A: A-positive blood to an A-negative client. This is because in ABO blood typing, individuals with blood type A have anti-B antibodies in their plasma. Therefore, if A-positive blood (which contains the A antigen) is given to an A-negative client (who has anti-A antibodies), there is a high risk of an acute hemolytic reaction due to the antibodies attacking the transfused blood cells. Choices B, C, and D are incorrect because they do not involve a mismatch of ABO blood types that would lead to a significant risk of acute hemolytic reaction. In choice B, O-positive blood can be safely transfused to an A-positive client as O blood is considered the universal donor. In choice C, O-negative blood can be safely given to an O-positive client as O-negative blood is compatible with all blood types. In choice D, B-positive blood can be safely administered to an AB-positive client as the AB blood type can receive both