ADPIE Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: Position lower extremities below level of heart. This intervention helps improve blood flow and perfusion to the lower extremities by utilizing gravity to assist in venous return. This is crucial for clients at risk for ineffective tissue perfusion post-cardiac surgery. A: Restricting fluid intake may lead to dehydration, which can worsen tissue perfusion. B: Ensuring the client avoids prolonged sitting is important for preventing blood clots, but it does not directly address tissue perfusion. D: Instructing the client to avoid leg exercises may hinder circulation and exacerbate issues related to tissue perfusion.

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.

Correct Answer: B

Rationale: The correct answer is B, weight gain, as it is not typically considered a warning sign of cancer. Changes in bladder and bowel habits (A), indigestion or difficulty in swallowing (C), and a nagging cough or hoarseness (D) are commonly associated with various types of cancer. Weight gain is more commonly linked to factors such as diet, exercise, and hormonal imbalances rather than cancer. It is important to be vigilant about the other warning signs and seek medical attention if any of those symptoms persist.

Correct Answer: C

Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance. A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery. B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client. D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.

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.