ADPIE Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This helps redistribute pressure, preventing constant pressure on one area and reducing the risk of developing pressure ulcers. Turning every 2 hours promotes circulation and relieves pressure points. A: Massaging reddened areas can worsen the condition by increasing friction and pressure. B: While a special water mattress can help in preventing pressure ulcers, turning frequently is more effective. D: Keeping the skin clean and dry is important for overall skin health but may not directly prevent pressure ulcers.

Correct Answer: B

Rationale: The correct answer is B: Use barrier techniques. When taking the blood pressure of a client with AIDS, using barrier techniques such as gloves and disposable equipment is crucial to prevent the transmission of the virus through blood or bodily fluids. Wearing a mask and gown (choice A) may not be necessary unless there is a risk of splashes or sprays. Washing hands thoroughly (choice C) is important, but alone may not provide sufficient protection. Choice D is incomplete.

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.

Correct Answer: C

Rationale: The correct answer is C: Puffiness at the site. This indicates infiltration of the infusion, where the medication or fluid leaks into the surrounding tissue instead of entering the bloodstream. Puffiness is a sign of fluid accumulation due to the infiltration. Redness at the site (A) may indicate infection, pain (B) can be due to various reasons, and exudate (D) may suggest infection or irritation, but they are not specific to infiltration. Infiltration assessment involves checking for swelling, coolness, and blanching around the infusion site.

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.