Question

The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing?

Answer 1

Correct Answers:

Primary

Rationale :

✔Primary prevention focuses on preventing disease or injury before it occurs. ✔Developmental testing in children aims to identify potential issues early to promote healthy development, which aligns with primary prevention. ✔Secondary prevention involves early detection and intervention (e.g., screenings for existing conditions). ✔Tertiary prevention manages long-term conditions to prevent complications.

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Answer 2

Correct Answers:

Acting

Rationale :

✔Values clarification involves three steps: choosing (exploring options), prizing (accepting the choice), and acting (demonstrating the decision through behavior). ✔The client’s plan to return to work despite blindness shows she has moved beyond deliberation and is implementing her values. ✔Acting is the final and most critical phase, as it reflects commitment to the clarified value (e.g., maintaining independence and professional identity). ✔This step distinguishes values clarification from mere intention.

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Answer 3

Correct Answers:

Document that the problem has been resolved and the goal has been met.

Rationale :

✔The client’s absence of vomiting/diarrhea for 5 days indicates the goal was achieved (symptoms resolved within 48 hours). ✔Nursing diagnoses are dynamic; once the problem no longer exists, it should be formally documented as resolved to avoid unnecessary interventions. ✔Continuing to list it on the care plan would be inappropriate unless new symptoms emerge. ✔This aligns with evidence-based practice, where care plans are updated based on client progress.

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Answer 4

Correct Answers:

Taking and recording vital signs.

Rationale :

✔UAPs are trained to perform routine, non-invasive tasks like vital signs, bathing, and bed-making under RN supervision. ✔Taking vital signs is a foundational UAP responsibility, as it does not require clinical judgment. ✔While assisting with bathing (C) is also within their scope, the question emphasizes delegation appropriateness, and vital signs are universally recognized as a UAP task. ✔State regulations may vary, but this aligns with standard nursing practice.

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Answer 5

Correct Answers:

The client will stop the flow of urine when voiding.

Rationale :

✔Stress urinary incontinence stems from sphincter incompetence, leading to leakage during physical exertion. ✔The ability to stop urine flow mid-void (via Kegel exercises) directly strengthens the pelvic floor muscles and sphincter control. ✔This outcome is specific and measurable, unlike vague goals like “improve incontinence.” ✔It targets the root cause (weak sphincter) rather than general symptoms.

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Answer 6

Correct Answers:

Primary prevention

Rationale :

✔Educating women about calcium intake to prevent osteoporosis is classic primary prevention. ✔It targets healthy individuals to reduce future disease risk through lifestyle modification. ✔Primary prevention includes vaccinations, health education, and dietary counseling.

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Answer 7

Correct Answers:

Public health agencies are funded by government grants to investigate and manage communicable diseases.

Rationale :

✔Public health agencies focus on population-level health, including disease surveillance, outbreak control, and health promotion. ✔Their mandate includes managing communicable diseases (e.g., tuberculosis, COVID-19) through research, education, and policy.

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Answer 8

Correct Answers:

Clara Barton

Rationale :

✔Clara Barton founded the American Red Cross in 1881 (incorporated in 1882) after volunteering during the Civil War. ✔ Her work established disaster relief and blood donation programs. ✔Florence Nightingale pioneered modern nursing but is unrelated to the Red Cross. ✔This distinction is key for nursing history questions.

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Answer 9

Correct Answers:

Fluid volume excess.

Rationale :

✔Heart failure causes fluid overload due to the heart’s inability to pump effectively, leading to pulmonary edema (crackles) and peripheral edema. ✔Fluid volume excess is the correct diagnosis, as it explains the symptoms. ✔Myocardial infarction involves heart tissue death, while atelectasis is lung collapse.

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Answer 10

Correct Answers:

Instruct the client to report promptly to the practitioner any decreased redness, swelling, pain, or discharge from the incision or drain sites.

Rationale :

✔Decreased redness/swelling indicates healing, not a complication. ✔The other options are correct: rest aids recovery , pain meds prevent under/overuse and avoiding alcohol with narcotics reduces sedation risks. ✔Nurses must teach clients to recognize true warning signs (e.g., increased redness, purulent discharge).

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RN Fundamental Final Exam

No.

1 : The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing?

2 : A client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counselling practice and work full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

4 : An unlicensed assistive person (UAP) is working in a rehabilitation unit. Which task would be appropriate for this person to delegate?

5 : The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

6 : A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent?

7 : Which of the following statements is true regarding types of health care agencies?

8 : Which of the following nursing pioneers established the Red Cross in the United States in 1882?

9 : The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

10 : During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

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