ADPIE Nursing Process Questions

Questions 75

ATI RN

ATI RN Test Bank

ADPIE Nursing Process Questions Questions

Question 1 of 5

Which diagnosis will the nurse document in a patient�s care plan that is NANDA-I approved?

Correct Answer: B

Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.

Question 2 of 5

Compartment syndrome is a potential complication of elbow fractures that decreases circulation to local neuromuscular structures. The nurse monitors circulation on a casted elbow because irreversible damage can develop if compartment syndrome lasts for more than:

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.

Question 3 of 5

The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient�s gastrointestinal tract is resuming normal function?

Correct Answer: B

Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.

Question 4 of 5

The nurse would expect which of the following would be included in the plan of care/

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.

Question 5 of 5

A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults?

Correct Answer: D

Rationale: The correct answer is D: Papillary carcinoma. This is the most common form of thyroid cancer in adults, accounting for about 80% of cases. It is typically slow-growing and has a good prognosis. Papillary carcinoma arises from the follicular cells of the thyroid gland. Follicular carcinoma (choice A) is less common than papillary carcinoma and arises from the follicular cells as well. Anaplastic carcinoma (choice B) is a highly aggressive and rare form of thyroid cancer. Medullary carcinoma (choice C) originates from the parafollicular C cells of the thyroid gland and is not as common as papillary carcinoma. Therefore, the most appropriate choice is D, papillary carcinoma, due to its high prevalence and relatively favorable prognosis.

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