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

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?

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. Which type of diet is recommended for patients with diverticulitis during an acute flare-up?

Correct answer: B

Rationale: During an acute flare-up of diverticulitis, a low-residue diet is recommended. This diet helps reduce bowel movements and minimizes irritants in the colon, which can help alleviate symptoms and promote healing. High-fiber diets, like choice A, are typically recommended for diverticulosis prevention but may exacerbate symptoms during a flare-up due to increased bulk in the stool. Low-fat (choice C) and high-protein (choice D) diets are not specifically indicated for diverticulitis flare-ups.

3. The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse’s priority intervention?

Correct answer: B

Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client’s comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (choice A) is not the priority at this time. While obtaining sterile dressing supplies (choice C) is important, ensuring pain management takes precedence. Assisting the client to the bathroom (choice D) is not directly related to the priority intervention of pain management before the whirlpool treatment.

4. Which of the following is a common side effect of the drug metformin?

Correct answer: A

Rationale: The correct answer is A, weight loss. Metformin is commonly associated with weight loss rather than weight gain. Metformin works by decreasing glucose production in the liver and improving insulin sensitivity, which can lead to weight loss in some individuals. Choices B, C, and D are incorrect. Weight gain is not a typical side effect of metformin. Drowsiness and hypertension are also not commonly associated with metformin use.

5. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

Correct answer: B

Rationale: The correct answer is to administer the digoxin. An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly prescribed for heart failure in newborns to help improve cardiac function. Holding the medication or notifying the healthcare provider is not necessary as the heart rate is normal for a newborn. Rechecking the apical rate in 1 hour is not needed since the heart rate is within the expected range.

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