ADPIE Nursing Process Questions

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.

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.

Correct Answer: B

Rationale: The correct answer is B: Wear gloves when providing mouth care. This is because standard precautions for AIDS include wearing gloves when in contact with bodily fluids, such as saliva during mouth care. Maintaining strict isolation (A) is not necessary as AIDS is not transmitted through casual contact. Keeping the client in a private room (C) is not required unless the client has an airborne infection. Wearing a gown when delivering food tray (D) is not necessary for standard precautions unless there is a risk of contamination with bodily fluids.

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.

Correct Answer: B

Rationale: The correct answer is B: Acute pain. The NANDA-I (North American Nursing Diagnosis Association International) approved diagnosis must meet specific criteria related to patient assessment data, defining characteristics, and related factors. Acute pain is a well-defined nursing diagnosis with specific defining characteristics and related factors, making it a suitable and approved option for inclusion in a patient's care plan. Sore throat, sleep apnea, and heart failure do not meet the criteria for a NANDA-I approved diagnosis as they lack the specificity and comprehensive assessment data required for a nursing diagnosis.