ADPIE Nursing Process Questions

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: Avoiding using soap on the irradiated areas. This is because soap can irritate the skin, leading to skin breakdown in a client at risk for impaired skin integrity due to radiation therapy. Avoiding soap helps to prevent further damage to the skin. Choice B is incorrect as talcum powder can further irritate the skin and should be avoided. Choice C is not relevant to preventing skin integrity issues. Choice D is incorrect because thoracic skin markings should not be removed as they are essential for accurate radiation delivery.

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: B

Rationale: The correct answer is B: Stool for Clostridium difficile test. In this scenario, the client is experiencing symptoms suggestive of a possible Clostridium difficile infection, a common complication of chemotherapy. The test is crucial to confirm the presence of C. difficile toxins in the stool, which would guide appropriate treatment with antibiotics such as metronidazole or vancomycin. A: Enzyme-linked immunosuppressant assay is not relevant in this context as it is used to measure levels of immunosuppressant drugs, not for diagnosing C. difficile infection. C: Flat palate X-ray of the abdomen is unnecessary and would not provide information about the cause of the symptoms. D: Electrolyte panel and hemogram are important for monitoring overall health status but do not directly address the specific issue of possible C. difficile infection.

Correct Answer: C

Rationale: The correct answer is C. The nurse should ask the NAP to record the patient's vital signs before administering medications. This is important for ensuring patient safety and monitoring any potential changes in the patient's condition. By having the NAP record the vital signs, the nurse can assess the patient's current status and make informed decisions regarding medication administration. Option A is incorrect because administering medications without knowing the patient's vital signs, especially if they are abnormal, can be risky. Option B is not the best choice as it delays addressing the missing vital signs. Option D is incorrect as omitting vital signs assessment is not in line with best practices for patient care.