ADPIE Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows: 1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity. 2. Oxygen toxicity can result in lung damage and other complications. 3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations. Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.

Correct Answer: A

Rationale: The correct answer is A: Monthly testicular self-examination. This is the best way to detect testicular cancer early because it allows individuals to become familiar with the normal size, shape, and texture of their testicles, making it easier to notice any changes or abnormalities. Self-examination is cost-effective, convenient, and can be done regularly to monitor for any signs of cancer. Annual physician examination (B) may not be frequent enough for early detection. Yearly digital rectal examination (C) is not relevant for detecting testicular cancer. Annual ultrasonography (D) is not recommended as a routine screening tool for testicular cancer.

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 hepatitis A is caused by a virus from the Picornaviridae family, not the enterovirus family. Hepatitis A spreads through contaminated food or water, not through sexual contact. It is true that hepatitis A occurs worldwide in areas with poor sanitation, but the virus is not from the enterovirus family. Choices B, C, and D are incorrect because they all pertain to hepatitis A characteristics.

Correct Answer: D

Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.