ADPIE Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Medulla. The medulla is located in the brainstem and plays a crucial role in controlling involuntary functions like breathing. It contains the respiratory center, which regulates the rate and depth of breathing. The medulla sends signals to the diaphragm and intercostal muscles to control breathing. The cerebrum (B) is responsible for higher brain functions, not breathing control. The cerebellum (C) coordinates movement and balance, not breathing. The thalamus (D) relays sensory information to the cerebral cortex, not involved in breathing regulation.

Correct Answer: A

Rationale: The correct answer is A: Cancerous lumps. Breast self-examination aims to detect any abnormal changes in the breasts, including potential cancerous lumps. Detecting cancerous lumps early increases the chances of successful treatment and improved outcomes. Choices B, C, and D are incorrect because while changes from previous self-examinations, areas of thickness or fullness, and fibrocystic masses can be important to note, the primary goal of breast self-examination is to identify any signs of breast cancer, such as cancerous lumps.

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: B

Rationale: The correct answer is B: Suppressor T cells. Suppressor T cells regulate the immune response by inhibiting the activity of other immune cells to prevent overreaction and maintain immune balance. They play a crucial role in preventing autoimmune diseases and excessive inflammation. Plasma cells (A) produce antibodies, Helper T cells (C) assist in activating other immune cells, and B lymphocytes (D) are involved in antibody production. Suppressor T cells specifically have the function of shutting down immune responses, making them the immune system�s shutoff mechanism.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition. 2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability. 3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication. Summary of Incorrect Choices: A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful. B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes. D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.