a family came to the emergency department with complaints of food poisoning which client should the nurse see first

ATI RN

ATI RN Custom Exams Set 3

1. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?

A. 32-year-old with diarrhea for 6 hours
B. 2-year-old with 1 wet diaper in 24 hours
C. 40-year-old with abdominal cramping
D. 10-year-old who is nauseated

Correct answer: B

Rationale: In cases of food poisoning, a 2-year-old with reduced urine output is a critical finding indicating dehydration, requiring immediate attention to prevent complications. The reduced urine output is a sign of decreased fluid intake or increased fluid loss, putting the child at high risk for dehydration. This client should be seen first to assess hydration status, initiate necessary interventions, and prevent further complications. While the other symptoms presented by the other clients are concerning, the 2-year-old's decreased urine output poses the most immediate threat to their well-being.

2. For a patient on lithium therapy, which dietary recommendation is essential?

A. Increase caffeine intake
B. Increase sodium intake
C. Increase protein intake
D. Increase fiber intake

Correct answer: B

Rationale: The correct answer is to increase sodium intake. Maintaining consistent sodium levels is crucial for patients on lithium therapy to prevent fluctuations in drug levels. Increasing caffeine intake (Choice A) is not recommended as it can interfere with lithium levels. While protein intake (Choice C) is important, it is not the essential dietary recommendation for patients on lithium therapy. Similarly, increasing fiber intake (Choice D) is not a key recommendation for these patients.

3. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL
B. Client with diabetes mellitus and a glycosylated hemoglobin A1c (HbA1c) of 7.0%
C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL
D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Choice A, chronic kidney disease with a serum creatinine of 1.6 mg/dL, though concerning, does not indicate an immediate need for follow-up. Choice C, heart failure with a BNP of 140 pg/mL, may require monitoring but not immediate follow-up. Choice D, a male client with anemia and normal hemoglobin and hematocrit levels, does not warrant immediate attention based on the provided information.

4. Which discharge instruction should the nurse provide to the client diagnosed with varicose veins who has received sclerotherapy?

A. Walk 15 to 20 minutes three (3) times a day.
B. Keep the legs in the dependent position when sitting.
C. Remove compression bandages before going to bed.
D. Perform Berger-Allen exercises (4) times a day.

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B, keeping the legs in the dependent position when sitting, is incorrect as it can increase venous pressure. Choice C, removing compression bandages before going to bed, is incorrect as compression should be maintained as per healthcare provider's instructions. Choice D, performing Berger-Allen exercises four times a day, is incorrect as these exercises may not be specifically recommended post-sclerotherapy.

5. When does the nurse act as a client advocate?

A. Pulling the curtain around the client's bed while changing a dressing
B. Contacting the health care provider to request a meeting for the client
C. Ensuring access to medical information by appropriate personnel only
D. All of the above

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' Acting as a client advocate involves various actions to protect the client's rights and well-being. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity. Contacting the health care provider to request a meeting for the client facilitates communication and addresses the client's needs. Ensuring access to medical information by appropriate personnel only safeguards the client's confidentiality and privacy. Therefore, all the actions mentioned in choices A, B, and C are examples of a nurse acting as a client advocate, making D the correct answer.