Which intervention is an example of the RN working in a health promotion role through primary prevention?

Administering a vaccine to a well child.

Obtaining a blood glucose level on a client with hypoglycemia (low blood sugar).

Educating a patient on wound care.

Administering a nebulizer treatment to a client with asthma.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering a vaccine to a well child is an example of the RN working in a health promotion role through primary prevention. Primary prevention is the level of prevention that aims to prevent disease or injury before it occurs. It involves reducing exposure to risk factors and enhancing protective factors. Vaccination is a primary prevention strategy that protects the child from contracting or spreading infectious diseases, such as measles, polio, or tetanus.

Choice B reason: Obtaining a blood glucose level on a client with hypoglycemia (low blood sugar) is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through tertiary prevention. Tertiary prevention is the level of prevention that aims to reduce the complications and disability associated with chronic or irreversible diseases or injuries. It involves providing treatment, rehabilitation, and support services. Obtaining a blood glucose level on a client with hypoglycemia is a tertiary prevention strategy that monitors the client's condition and prevents further deterioration or complications, such as coma or seizures.

Choice C reason: Educating a patient on wound care is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through secondary prevention. Secondary prevention is the level of prevention that aims to detect and treat diseases or injuries early, before they become more serious or chronic. It involves screening, diagnosis, and intervention. Educating a patient on wound care is a secondary prevention strategy that helps the patient to prevent infection, promote healing, and avoid complications, such as scarring or gangrene.

Choice D reason: Administering a nebulizer treatment to a client with asthma is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through tertiary prevention. Tertiary prevention is the level of prevention that aims to reduce the complications and disability associated with chronic or irreversible diseases or injuries. It involves providing treatment, rehabilitation, and support services. Administering a nebulizer treatment to a client with asthma is a tertiary prevention strategy that helps the client to relieve symptoms, improve lung function, and prevent exacerbations, such as asthma attacks.

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Correct Answer is C

Explanation

Choice A reason: A teacher who notices a mole change but doesn't have time to see a dermatologist is not in a state of wellness. A mole change could indicate skin cancer, which is a serious health problem that requires prompt medical attention. Ignoring or delaying the diagnosis and treatment of skin cancer could compromise the teacher's physical and emotional well-being.

Choice B reason: A fitness trainer who is struggling to cope with the death of her mother is not in a state of wellness. The death of a loved one is a major life stressor that can affect the fitness trainer's mental and emotional health. Grieving is a normal and healthy process, but it can also interfere with the fitness trainer's daily functioning and quality of life. The fitness trainer may need professional help or support from family and friends to cope with the loss.

Choice C reason: A hospice client who is comfortable and at peace with dying is in a state of wellness. Wellness is not only the absence of disease, but also the presence of positive health behaviors and attitudes. A hospice client who is comfortable and at peace with dying has accepted the reality of their condition and has made peace with themselves and others. The hospice client may also receive palliative care, which aims to relieve pain and suffering and improve the quality of life for terminally ill patients and their families.

Choice D reason: A type 1 diabetic who gives himself extra insulin so he can eat cookies is not in a state of wellness. A type 1 diabetic who gives himself extra insulin so he can eat cookies is engaging in unhealthy and risky behavior that could harm his physical health. Extra insulin could cause hypoglycemia, which is a condition where the blood sugar level drops too low and can lead to seizures, coma, or death. Eating cookies could also increase the blood sugar level and contribute to complications such as nerve damage, kidney damage, or cardiovascular disease. A type 1 diabetic who wants to eat cookies should follow a balanced diet and monitor his blood sugar level regularly.

A. Stop the KCl infusion B. Administer oral KCl C. Encourage fluids for dilution D. Call the pharmacy

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood, or hyperkalemia, can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium, which is the KCl infusion, and monitor the client's vital signs, electrocardiogram, and symptoms.

Choice B reason: This is not the correct answer because administering oral KCl is not the first or appropriate action that the nurse should take. Oral KCl would increase the potassium level in the blood, which is already too high. The nurse should avoid giving any potassium supplements or foods that are high in potassium, such as bananas, oranges, and potatoes.

Choice C reason: This is not the correct answer because encouraging fluids for dilution is not the first or effective action that the nurse should take. Fluids alone would not lower the potassium level in the blood, but rather dilute the concentration of other electrolytes, such as sodium and calcium. The nurse should administer fluids only as prescribed by the physician, and in conjunction with other treatments, such as diuretics, insulin, or sodium bicarbonate.

Choice D reason: This is not the correct answer because calling the pharmacy is not the first or priority action that the nurse should take. Calling the pharmacy may be necessary to obtain the medications that can lower the potassium level in the blood, such as diuretics, insulin, or sodium bicarbonate. However, the nurse should first stop the KCl infusion and notify the physician, who will order the appropriate medications and dosages.

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Which intervention is an example of the RN working in a health promotion role through primary prevention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify which client could be considered to be in a state of wellness?

Correct Answer is C

Explanation

The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?

Correct Answer is A

Explanation

Twenty minutes after administering pain medication to the patient, the nurse asks if the patient's pain level has decreased. What phase of the nursing process does this demonstrate?

The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate?

When shown an Amsler grid, the client reports seeing wavy, distorted lines. The client also states his center of vision is dark and he has no sense of depth perception. The nurse suspects the client has which of the following conditions?

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

The RN asks the client to demonstrate proper use of his inhaler. This is an example of which domain of learning?

A client is 24 hours post-op after having a colon resection (part of the colon is removed and the healthy ends are sewn back together). His abdominal incision is dry and intact, but the nurse notes that bowel sounds have not returned. What condition is this client likely experiencing?

Which of the following clients has a modifiable risk factor for osteoporosis?

A nurse is collecting data from a client who has open-angle glaucoma. Which of the following symptoms should the nurse expect the patient to report?