ADPIE Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment. Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow. Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis. Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.

Correct Answer: B

Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.

Correct Answer: A

Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals. Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.

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: C

Rationale: The correct answer is C: Immediate recognition of respiratory distress. This is crucial when caring for a client with influenza as the virus can lead to respiratory complications. Prompt recognition allows for timely intervention and prevents further deterioration. A: Maintaining airborne transmission is incorrect as the goal is to prevent the spread of influenza through droplet precautions, not airborne transmission. B: Oxygen administration may be necessary for severe cases of influenza, but immediate recognition of respiratory distress takes precedence in the nursing interventions. D: Complete bed rest is not recommended for influenza as mobilization and deep breathing exercises are important to prevent complications like pneumonia.