ADPIE Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: Wash and inspect the feet daily. This is important for clients with diabetes mellitus to prevent complications like foot ulcers. Daily foot care helps detect any issues early. Choice A is incorrect as it is not recommended to use commercial preparations without medical advice. Choice C is incorrect as walking barefoot can increase the risk of injury and infection. Choice D is incorrect as cutting toenails by rounding edges can lead to ingrown toenails, which can be dangerous for clients with diabetes.

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: 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

Correct Answer: A

Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.

Correct Answer: C

Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.