ADPIE Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A because thalassemia is a genetic blood disorder that can cause anemia and fatigue. By maintaining the client on bed rest and protecting them from infections, we can help prevent complications such as fatigue and infections due to reduced red blood cell production. Ambulating the client frequently (choice B) may lead to increased fatigue and risk of injury. Advising to drink 3 quarts of fluid per day (choice C) is not specific to thalassemia treatment and could potentially worsen symptoms. Instructing the client to elevate lower extremities (choice D) is not directly related to managing thalassemia and may not provide significant benefits in this context.

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: 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: C

Rationale: The correct answer is C: Hypoglycemia. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Hypoglycemia is not directly related to metabolic alkalosis but can be seen in other conditions like diabetes or fasting. Evaluating for hypocalcemia (A) is important as alkalosis can lead to decreased ionized calcium levels. Hypokalemia (B) is common in metabolic alkalosis due to potassium loss. Hypoxemia (D) is not directly related to metabolic alkalosis but can occur in severe cases due to respiratory compensation. Therefore, hypoglycemia is the least relevant in assessing metabolic alkalosis.

Correct Answer: B

Rationale: The correct answer is B: Arm and leg trembling. With a blood glucose level of 470 mg/dl in a client with type I diabetes mellitus, the most likely finding is arm and leg trembling, which is a common symptom of hypoglycemia. This occurs due to the body's response to low blood sugar levels, causing tremors as a compensatory mechanism to increase glucose utilization. The other choices are incorrect because cool, moist skin is a sign of hypoglycemia, rapid thready pulse is a sign of shock or hypovolemia, and slow shallow respirations are not typically associated with high blood glucose levels in this scenario.