FUNDAMENTALS OF NURSING

FON – 01
Fecal Occult Blood
- Blood in the stool/bleeding in the GI tract

3 days before the test: avoid

1. Vegetables and Fruits: beets, broccoli, cantaloupe, cauliflower, cucumber, grapefruit, horseradish,
mushroom, radish and turnip
2. Read meat
3. Pain reliever
4. Vitamin C

FON – 02
With 1 hour of sample collection will give the most accurate result

FON – 03
IVP – Intravenous Pyelogram
 X-ray exam
 Injection of contrast in IV Line
 Evaluate your Kidney, Bladder, Ureters
 Help dx. blood in the urine/pain in your side or lower back

Left Nephrectomy – removal of kidney

(+) Foley Catheter/Indwelling Catheter

 Use sizes such as #8 or #10 for children
#14 or #16 for adults
Men frequently require a larger size than women, for example, #18.
 Balloon size: Adult – 5mL, Child – 3mL
 Lubricate the catheter 2.5 to 5 cm (1 to 2 in.) for females, 15 to 17.5 cm (6 to 7 in.) for males
 For an indwelling catheter, secure the catheter tubing to the thigh for female clients or the upper thigh or
lower abdomen for male clients to prevent movement on the urethra or excessive tension or pulling on the
indwelling balloon
 Purposes:
 To relieve urinary retention or bladder outlet obstruction
 For selected surgical procedures
 To facilitate accurate measurement of urinary output for critically ill clients whose output needs to
be monitored hourly
 To provide for intermittent or continuous bladder drainage and/ or irrigation
 To prevent urine from contacting an incision after perineal surgery if needed
 To assist in healing of open sacral or perineal wounds in incontinent clients
 To improve comfort for end-of-life care if needed.

You need to clamp the Tubing below the port for 15-20 mins/10-15 mins. (to get fresh urine)
Attach the Luer-lock syringe to the sample port of the catheter and withdraw 10-30 mL of urine; remove the syringe
and unclamp the tubing.

FON – 04
What is a mid-stream urine sample?
A mid-stream urine sample means you don't collect the first or last part of urine that comes out. This reduces the risk
of the sample being contaminated with bacteria from: your hands. the skin around the urethra, the tube that carries
urine out of the body.

What does a midstream urine test for?

A midstream specimen of urine (MSU) is tested to look for infection. Symptoms of a urine infection can include pain
when you pass urine and passing urine frequently.

FON – 05
What is a 24-hour urine collection?
 A 24-hour urine collection is a simple lab test that measures what’s in your urine.
 The test is used to check kidney function.
 A 24-hour urine collection is done by collecting your urine in a special container over a full 24-hour period.
  The container must be kept cool until the urine is returned to the lab.

Why? Diabetic nephropathy. High blood pressure. Lupus nephritis. Frequent urinary tract infections. Prolonged
urinary tract blockage. Nephrotic syndrome. Polycystic kidney disease. Interstitial nephritis or pyelonephritis. Kidney
stones (nephrolithiasis).

How?
 The 24-hour collection may start at any time during the day after you urinate. But your healthcare provider
may tell you when to start. It is common to start the collection the first thing in the morning. It is important
to collect all urine in the following 24-hour period.
 Don't save the urine from your first time urinating. Flush this first specimen, but note the time. This is the
start time of the 24-hour collection.
 All urine, after the first flushed specimen, must be saved, stored, and kept cold. This means keeping it either
on ice or in a refrigerator for the next 24 hours.
 Try to urinate again at the same time, 24 hours after the start time, to finish the collection process. If you
can’t urinate at this time, it is OK.

FON – 08
Cleaning Enema
 Assist the adult client to a left lateral position, with the right leg as acutely flexed as possible, with the linen-
saver pad under the buttocks. Rationale: This position facilitates the flow of solution by gravity into the
sigmoid and descending colon, which are on the left side. Having the right leg acutely flexed provides for
adequate exposure of the anus.
 Insert the tube 7 to 10 cm (3 to 4 in.). Rationale: Because the anal canal is about 2.5 to 5 cm (1 to 2 in.) long
in the adult, insertion to this point places the tip of the tube beyond the anal sphincter into the rectum.
 During most low enemas (an enema in which the injected material goes no higher than the rectum), hold or
hang the solution container no higher than 30 cm (12 in.) above the rectum. Rationale: The higher the
solution container is held above the rectum, the faster the flow and the greater the force (pressure) in the
rectum. During a high enema (an enema in which the injected material reaches the colon), hang the solution
container about 30 to 49 cm (12 to18 in.). Rationale: Fluid must be instilled farther for a high enema to clean
the entire bowel. See agency protocol.
 Administer the fluid slowly. If the client complains of fullness or pain, lower the container or use the clamp to
stop the flow for 30 seconds, and then restart the flow at a slower rate. Rationale: Administering the enema
slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature
ejection of the solution.
 Request that the client retain the solution for the appropriate amount of time, for example, 5 to 10 minutes
for a cleansing enema or at least 30 minutes for a retention enema.

Choice A: Clamping the enema tubing does not reduce the flow of the fluid but instead it stops the flow of the fluid
Choice B: this is during the insertion of enema tip (relaxation of the anal sphincter)
Choice D: No relevance

FON – 12
FON – 15 and 16
Subcutaneous Injection:
 Among the many kinds of drugs administered subcutaneously are vaccines, insulin, and heparin
 Common sites for subcutaneous injections are the outer aspect of the upper arms and the anterior aspect of
the thighs. Other areas that can be used are the abdomen, the scapular areas of the upper back, and the
upper ventrogluteal and dorsogluteal areas.
 Only small doses (0.5 to 1 mL) of medication are usually injected via the subcutaneous route.
 Generally, a 1- or 2-mL syringe is used for most subcutaneous injections.
 Generally, a #25-gauge, 5/8-inch needle is used for adults of normal weight and the needle is inserted at a
45° angle; a 3/8-inch needle is used at a 90° angle. A child may need a 1/2-inch needle inserted at a 45°
angle.
 A 45° angle is used when 1 inch of tissue can be grasped at the site; a 90° angle is used when 2 inches of
tissue can be grasped.

FON – 18

FON – 21
Cleansing Enema
Cleansing enemas are intended to remove feces.
They are given chiefly to:
 Prevent the escape of feces during surgery.
 Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy).
 Remove feces in instances of constipation or impaction.

Carminative Enema
 A carminative enema is given primarily to expel flatus.
 The solution instilled into the rectum releases gas, which in turn distends the rectum and the colon, thus
stimulating peristalsis.
 For an adult, 60 to 80 mL of fluid is instilled.

Retention Enema
 A retention enema introduces oil or medication into the rectum and sigmoid colon.
 The liquid is retained for a relatively long period (e.g., 1 to 3 hours).
 An oil retention enema acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating
passage of the feces.
  Antibiotic enemas are used to treat infections locally, anthelmintic enemas to kill helminths such as worms
and intestinal parasites, and nutritive enemas to administer fluids and nutrients to the rectum.

Return Flow Enema

 A return-flow enema, also called a Harris flush, is occasionally used to expel flatus.
 Alternating flow of 100 to 200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis.
 This process is repeated five or six times until the flatus is expelled and abdominal distention is relieved.

FON – 48
Answer: 2.
Rationale:
Options 1 and 3 are psychomotor, and
4 is under the cognitive domain.

FON – 49
Answer: 3.
Rationale:
Options 1 and 2 are passive learning strategies. Learning is faster and retention better when the learner is actively
involved.
Option 4 promotes affective learning about adapting to a chronic health condition and is important. However, the
question asks about learning diet information.

FON – 50
Answer: 3.
Rationale:
Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally
greatest when a person recognizes a need and believes the need will be met through learning.
Clients who struggle with rules or following prescribed courses of treatment are not motivated to learn the best
reason for their particular plan of action (option 1).
The client who is already waiting to go home may be motivated for that, but not to the extent of being ready to learn
how to achieve this end (option 2).
Motivation must be experienced by the client, not by someone else, as in being a “coach” for newcomers (option 4).

FON – 51
Answer: 1.
Rationale:
Individuals learn in various ways, such as visually, group learning, auditory, and participatory. The individual knows
how learning has occurred in the past.
Option 2 is a component of the implementation phase of teaching, and the question is asking how to assess a client’s
style of learning.
Options 3 and 4 involve others and it is best to ask the client.

FON – 52
Answer: 3.
Rationale:
Options 1 and 4 are not specific enough because they do not include the specific learning need.
Option 2 is a wellness nursing diagnosis; the data would need to address that the client is seeking health information
and why in order to be the correct answer

FON – 53
Answer: 2, 3, and 5.
Rationale:
Options 2, 3, and 5 are open-ended questions that will give the client the opportunity to provide information that will
help the nurse assess level of knowledge and subsequently provide and discuss needed information with the client.
Options 1 and 4 are closed-ended (yes or no) questions. A “no” answer may cause a discussion but it will be difficult
for the nurse to assess if it is the information the client really wants to know

FON – 54
Answer: 1, 2.
Rationale:
The inability to identify changes in the skin around the stoma would indicate that instruction has not been effective.
The client’s stating he does not want to perform self-care to the ostomy or the client’s asking his wife to learn the
care would indicate that effective learning did not occur.

FON – 55
Answer: 3.
Rationale:
All are important factors to assess. The priority, however, would be the potential economic factor because the
medications can be very expensive and the client may not take them if he or she cannot afford them
FON – 56
. Answer: 3.
Rationale:
This option is the easiest for the nurse to evaluate.
Option 1 is difficult to evaluate because “understand” is too vague.
Option 2 refers more to an affective outcome and the question is asking about a cognitive outcome.
Option 4 is telling more about the husband than the client

FON – 57
Answer: 2.
Rationale:
This is the only option that clearly reflects the teaching process, the evaluation method, and the response of the
client indicating evidence of learning.

FON – 58
Answer: 2.
Rationale:
Nurses who utilize good critical-thinking skills are able to think and act in areas where there are neither clear answers
nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many
points to consider (good and bad), and choosing between treatment options can cause conflict among family
members. The nurse in this case must use creativity, analysis based on science, and problem-solving skills, all of
which contribute to critical-thinking skills.
Options 1, 3, and 4 do not require much reasoning.

FON – 59
Answer: 1.
Rationale:
The nurse recognizes that many assumptions (beliefs) could interfere with the client eating— such as that the food
presented is not culturally appropriate. These assumptions must be clarified with the process of clinical reasoning.
Options 2 and 3 reach conclusions not supported by the facts.
In option 4, the nurse has made a judgment or has an opinion that may not be accurate. Also, the nurse is acting
without assessment. Implementation should be preceded by assessment.

FON – 60
Answer: 2.
Rationale:
Reviewing evidence-based literature and identifying similarities in the clinical manifestations of symptoms is an act of
clinical reasoning. Past experiences in care enhance the nurse’s ability to recognize and respond in the delivery of
client-centered care.
Clinical judgment in nursing is a decision-making process to ascertain the right action to implement at the
appropriate time during client care (option 1).
Reflection is the nurse’s review of the care provided to determine strategies to improve future care (option 3).
Intuition is a problem-solving approach that relies on a nurse’s inner sense (option 4).

FON – 61
Answer: 1.
Rationale:
The research method uses a research study-based approach to problem-solving. Trial and error (option 2) and
intuition (option 3) would involve unstructured approaches resulting in less predictable results.
The nursing process generally uses application of known interventions, previously determined by the scientific
(research) process (option 4).

FON – 62
Answer: 2.
Rationale:
Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth
sense, hunch, instinct, feeling, or suspicion. Clinical experience allows the nurse to recognize cues and patterns and
begin to reach correct conclusions using intuition. Finding no cause for concern in the physical assessment of the
client, the nurse is not satisfied and continues to assess the client’s surroundings, finding the error.
Trial and error is solving problems through a number of approaches until a solution is found (option 1).
Judgment is not part of problem solving (option 3).
The scientific method requires that the nurse evaluate potential solutions to a given problem in an organized, formal,
and systematic approach (option 4).
FON – 63
Answer: 2.
Rationale:
The nurse’s intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct
conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client’s clinical picture
more fully.
Option 1 supports appropriate nursing actions, but the client’s respiratory status should be assessed first.
Usually, a physician must order a chest x-ray (option 3).
The rapid response team (option 4) may be needed if the client’s condition becomes more critical.

FON – 64
Answer: 1.
Rationale: By reconsidering the type of dressing used based on research, the nurse is using integrity.
Options 2 and 3 are critical thinking attitudes characterized by an awareness of the limits of one’s own knowledge,
and being trustworthy.
Option 4 indicates an attitude of not being easily swayed by the opinions of others.

FON – 65
Answer: 1, 2, 4, 5.
Rationale:
While option 3 might be true, medicine and nursing have evolved tremendously, and so has the need for nurses to be
critical thinkers. According to R. Alfaro LeFevre’s Top 10 Reasons to Improve Thinking, patients are sicker, with
multiple problems, and so nursing care requires a more critical form of thinking in order to meet their nursing needs;
redesigning care delivery is useless if nurses don’t have the thinking skills required to deal with today’s world;
consumers and payers demand to see evidence of benefits, efficiency, and results; and today’s progress often creates
new problems that can’t be solved by old ways of thinking.

FON – 66
Answer: 2.
Rationale:
The nurse recognizes the need to obtain further information from the client in order to respond directly to the
client’s statement.
Option 1 passes off the client’s educational needs to another practitioner.
Options 3 and 4 are nontherapeutic.

FON – 67
Answer: 4.
Rationale:
A nurse thinks critically, evaluates possible solutions, and uses problem-solving. Intuition (option 1) is not a sufficient
basis for implementing wound care when significant data on alternative care strategies are available.
Research (option 2) is a more comprehensive rigorous process and not typically implemented while caring for an
infected wound.
Trial and error (option 3) is unsafe and inappropriate for care of an infected wound.

FON – 68
Answer: 3.
Rationale:
Delivery or organized care is not part of the nursing process, though each phase is interrelated (option 1).
The nursing process is not part of the medical model as nurses treat the client’s response to the disease or problem
(option 2).
The nursing process is individualized for each client’s care plan. It is not about standardizing care (option 4).

FON – 69
Answer: 1, 2, 5.
Rationale:
Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be
prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing
and collaborative problems. Developing a plan and specifying goals and outcomes is part of the planning phase.

FON – 70
Answer: 2.
Rationale:
Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family).
Subjective data are covert (reported or an opinion), whereas objective data can be measured or validated (weight—
option 1, edema—option 3). If the spouse had stated that the client had eaten only toast and tea, this would be
secondary objective (measured) data.

FON – 71
Answer: 2.
Rationale:
The nurse should use a combination of directive and nondirective approaches during the interview to determine
areas of concern for the client. Simply noting the concern, without dealing with it, or passing the questions off to the
doctor can leave the impression that the nurse does not care about the client’s concerns or dismisses them as
unimportant (options 1 and 3).
A closed question (option 4) does not allow the client to offer much information, besides yes/no or one-word
answers.

FON – 72
Answer: 4.
Rationale:
Frameworks help the nurse be systematic in data collection.
Other members of the healthcare team may use very different conceptual organizing frameworks so data may not
correlate (option 1).
Cost-effective care (option 2) is more likely to occur with systematic application of the nursing process, but use of a
framework for assessment alone may not accomplish this goal.
Because the framework is structured and because of the nature of client needs and problems, creativity and intuition
in care planning are not assured (option 3)

FON – 73
Answer: 1.
Rationale:
Assessing provides a database of the client’s physiologic and psychosocial responses to his or her health status. Client
strengths and problems (option 2) are identified in the diagnosing phase of the nursing process; a care plan is
established (option 3) in the planning phase; and care, prevention, and wellness promotion (option 4) are part of the
implementing phase

FON – 74
Answer: 3.
Rationale:
In validating, the nurse confirms that data are complete and accurate. Subjective data are collected in the collecting
activity (option 1),
a framework is applied to the data in the organizing activity (option 2),
and data are recorded in the documenting activity (option 4).

FON – 75
Answer: 1.
Rationale:
The nursing process focuses on client needs.
It is dynamic rather than static (option 2),
emphasizes client responses rather than physiology and illness (option 3),
and is collaborative rather than used exclusively by nurses (option 4)

FON – 76
Answer: 4.
Rationale:
Interpreting collected data is necessary to help validate their accuracy.
Observing includes the senses of smell, hearing, and touch in addition to vision (option 1).
Observing must often be performed simultaneously with other activities (option 2).
A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most
important data first (option 3).

FON – 77
Answer: 2, 4, and 5.
Rationale:
The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to
respect the client’s personal space is about 3 feet. Using a standard form will help ensure the nurse doesn’t omit
gathering any vital information.
Lighting should be at a normal level—neither bright nor dim (option 1). The nurse should be at the same height as the
client, usually sitting, at approximately a 45° angle facing the client.
The nurse standing over the client creates an uncomfortable atmosphere for an interview (option 3).

FON – 78
Answer: 3.
Rationale:
Learning from peers and seasoned nurses is helpful but does not take the place of didactic information (options 1 and
2).
Experience teaches much information, but it never takes the place of concrete, scientific theory (option 4).

FON – 79
Answer: 2.
Rationale:
Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the
cause (etiology) of the problem. Increased fluid volume is the nursing diagnosis, and edema of the lower extremity is
the sign, symptom, or critical attribute. The cause is known

FON – 80
Answer: 1.
Rationale:
States the relationship between the stem (impairment in caregiver role) and the cause of the problem.
Option 2: The diagnostic statement says the same thing as the related factor (falls and collapse).
Option 3: It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement.
Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep
deprivation and does not direct intervention).

FON – 81
Answer: 4.
Rationale:
The PES format assists with comprehensive and accurate organization of client data. More efficient planning may or
may not reduce healthcare costs. Nursing diagnostic statements should be confirmed with the client but using PES
does not ensure this. PES statements can be wellness or illness focused.

FON – 82
Answer: 1.
Rationale:
A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to
prevent or treat the problem. If nursing care alone (whether that care involves independent or dependent nursing
actions) can treat the problem, a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical
diagnosis is indicated.
FON – 83
Answer: 1.
Rationale:
A syndrome diagnosis is associated with a cluster of other diagnoses (in this situation, urinary elimination alteration,
impaired skin integrity, and powerlessness). Currently, there are six syndrome diagnoses on the NANDA International
list. The others are incorrect options.

FON – 84
Answer: 3.
Rationale:
Diagnostic labels are continuously reviewed and revised as indicated by research—much more of which is needed.
The original taxonomy has been replaced by Taxonomy II and is no longer based on a nurse theorist (options 1 and 2).
New diagnoses are approved by NANDA International’s Diagnostic Review Committee, not by a vote of nurses (option
4).

FON – 85
Answer: 1, 4, and 5.
Rationale:
A client’s movement toward a goal (option 1) or
whose behavior is inconsistent with population norms (options 4 and 5) represents a cue that further analysis toward
creating a nursing diagnosis is required.
Corrected vision (option 2) and bladder and bowel control at age 18 months
(option 3) are consistent with population norms.

FON – 86
Answer: 4.
Rationale:
Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least
useful and not relevant in this case.
The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option 1).
Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had
surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this
shift (option 2).
Discharge planning needs to start on admission to ensure adequate client preparation for management of health
needs outside the health agency (option 3).

FON – 87
Answer: 2.
Rationale:
The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and
client. Factors in this case include the distance between the client’s home and the hospital and the fact that therapy
is ordered on a twice daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other
alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the
area who may be able to assist with the therapy).

FON – 88
Answer: 2.
Rationale:
More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority.
Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and
requires nursing intervention now.
The client’s pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to
be effective (option 1). Although the constipation is probably bordering on abnormal, a nursing intervention would
most likely begin with oral treatment, which is not possible due to the nausea.
More invasive interventions such as an enema or suppository would not be commonly administered the first day
postoperative (option 3).
Wound infection can occur, but there are no data to indicate that this requires a change in the current plan (option
4).

FON – 89
Answer: 1.
Rationale:
Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met.
Ambulating without a walker by a certain date is specific as well as measurable.

FON – 90
Answer: 3.
Rationale:
Although there may be standard policies or routines for measuring intake and output, the nursing intervention
should specify if this is to be done “routinely” or at specific intervals (e.g., q4h). The nurse is also aware, however,
that critical thinking indicates that the intake and output should be monitored more frequently than ordered if
assessment reveals abnormal findings

FON – 91
Answer: 4.
Rationale:
An individualized care plan is tailored to meet the unique needs of a specific client, needs that are not addressed by
the standardized care plan. In this situation, the client had complications following a relatively routine procedure,
something that is unplanned and a rare occurrence and must fit with the needs of the client
FON – 92
Answer: 1.
Rationale:
Goal statements provide the standard against which outcomes are measured.
Nursing diagnoses are prioritized before goals are written (option 2).
Both independent and dependent interventions may be appropriate for any goal (option 3).
Clarity of the goal does not influence delegation of the intervention (option 4).

FON – 93
Answer: 4.
Rationale:
NOC outcomes should reflect both the nurse’s and the client’s values of what is trying to be achieved.
The outcomes still must be customized (option 1),
but address only one nursing diagnosis at a time (option 2).
Outcomes are narrow or specific end points, not broad (option 3)

FON – 94
Answer: 1.
Rationale:
Interventions should address the etiology of the nursing diagnosis.
Both independent and dependent interventions should be selected if appropriate (option 2) and
several interventions may be needed for a single outcome (option 3).
Both action and assessment-type interventions can be used (option 4).

FON – 95
Answer: 2.
Rationale:
Person (individual or client), environment, health, and nursing are relevant when providing care for any client
whether in the hospital, at home, in the community, or in elementary school systems. These elements can be used to
understand diseases, conduct and apply research, and develop nursing theories, as well as implement the nursing
process

FON – 96
Answer: 2.
Rationale:
Continuing education refers to formalized experiences designed to enhance the knowledge or skill of practitioners.
The other answers are examples of in-service education, which is designed to upgrade the knowledge or skills of
current employees with regard to the specific setting, and is usually less formal in presentation.

FON – 97
Answer: 3.
Rationale:
Health promotion focuses on maintaining normal status without consideration of diseases.
Option 1 is an example of illness prevention.
Option 2 is aesthetic (i.e., not needed for health promotion or disease prevention).
Option 4 focuses on disease detection.
FON – 98
Answer: 2, 3, and 4.
Rationale:
Significant evidence exists that a trusting relationship with the provider, effectiveness of the medication, and simple
dosing regimen are important predictors of adherence to a medical regimen.
Neither education nor sex has been shown to be a predictive factor (options 1 and 5).

FON – 99
Answer: 1.
Rationale:
Although not always practical, direct observation is the best method to measure adherence (for example, watching
clients who are addicted to heroin actually take their methadone dose).
Because lack of adherence may be life threatening or damaging to the client as well as others, waiting until the client
displays illness and waiting until laboratory values reflect a lack of adherence are not the best methods (options 2
and 3).
Client report or recall is not always accurate, even if the client believes he or she is telling the truth (option 4).

FON – 100
Answer: 3.
Rationale:
Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary
preventions.
Treatment of a disease such as with antibiotic therapy (option 1) or
surgery (option 4) is secondary prevention,
while rehabilitation efforts following an illness (option 2) are considered tertiary prevention.