ATI Fluid and Electrolytes Exam 4 2024
A nurse is caring for a client who has a prescription to receives one unit of packed red blood
cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood
bank. Which of the following actions should the nurse take? - Verify the unit of blood with
another nurse.
Rationale: The unit of blood is compatible with the client's blood type. However, the nurse
should ensure that the blood unit had been verified by two nurses before initiating the
transfusion.
A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the
following actions should the nurse take? - Apply a blood pressure cuff set to 30 mm Hg.
Rationale: Instead of using a tourniquet, the nurse should apply a blood pressure cuff set to 30
mm Hg prior to starting an IV for this client. This will help protect the client's extremity from
bruising and bleeding.
A nurse is participating in a blood drive and is taking a donation from a client who has type A-
blood. The client asks the nurse what blood types can receive their blood donation. Which of the
following responses should the nurse make? (Select all that apply.) - A+
AB-
AB+
A-
A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia.
Which of the following actions should the nurse take first? - Elevate the head of the client's bed.
Rationale: The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to elevate the head of the client's bed. Placing the client in the Fowler's
or semi-Fowler's position will promote effective breathing and chest expansion.
A nurse is reviewing a client's laboratory results. Which of the following results should the nurse
report to the provider? - Magnesium 3 mEq/L
Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1
mEq/L. Therefore, the nurse should report this finding to the provider.
A nurse is participating in blood drive and is taking a donation from a client who has type O+
blood. The client asks the nurse what type of blood they can receive. Which of the following
statements should the nurse make? - "You can receive a blood donation from donors with type
O- and type O+ blood."
Rationale: Clients who have type O+ blood can only receive blood from donors who have type
O- or type O+ blood. Clients who have type O- blood are universal donors, meaning that anyone
can receive their blood, regardless of blood type.
, A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL
of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100
mL/hr. Which of the following amounts represents the client's intake over the last 4 hr? - 1,120
mL
Rationale: The client has taken in: 480 mL of water + 240 mL of coffee + (100 mL of fluids x 4
hr). 720 mL + 400 mL = 1,120 mL. The client's total intake in 4 hr is 1,120 mL.
A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing
metabolic alkalosis. The nurse should identify that this action is part of which of the following
steps of the nursing process? - Evaluation
Rationale: Reviewing the client's ABG values is part of the evaluation stage of the nursing
process. During the evaluation stage, the nurse should determine if the actions taken in the
implementation stage were successful in meeting the goals in the client's plan of care.
A nurse is receiving report on four clients. The nurse should identify that which of the following
clients may be experiencing hypomagnesemia? - A client who has vomited four times during the
last 8 hr.
Rationale: Nausea and vomiting are early manifestations of hypomagnesemia.
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following
actions should be the goal of treatment for a client? - Increase the carbon dioxide level.
Rationale: A state of respiratory alkalosis indicates that the client's carbon dioxide level is
currently below the expected reference range. The goal of treatment should be to raise the level
of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm
Hg.
A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed
red blood cells. The nurse should plan to infuse the blood over which of the following lengths of
time? - 4 hr
Rationale: Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for
circulatory overload, such as a client who has heart failure, a disorder in which compromised
cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be
administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart.
A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should
identify that which of the following findings is an indication that the treatment has been
effective? (Select all that apply.) - The client states their muscle spasms are absent.
The client denied being confused.
A nurse is caring for a client who has a prescription to receives one unit of packed red blood
cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood
bank. Which of the following actions should the nurse take? - Verify the unit of blood with
another nurse.
Rationale: The unit of blood is compatible with the client's blood type. However, the nurse
should ensure that the blood unit had been verified by two nurses before initiating the
transfusion.
A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the
following actions should the nurse take? - Apply a blood pressure cuff set to 30 mm Hg.
Rationale: Instead of using a tourniquet, the nurse should apply a blood pressure cuff set to 30
mm Hg prior to starting an IV for this client. This will help protect the client's extremity from
bruising and bleeding.
A nurse is participating in a blood drive and is taking a donation from a client who has type A-
blood. The client asks the nurse what blood types can receive their blood donation. Which of the
following responses should the nurse make? (Select all that apply.) - A+
AB-
AB+
A-
A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia.
Which of the following actions should the nurse take first? - Elevate the head of the client's bed.
Rationale: The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to elevate the head of the client's bed. Placing the client in the Fowler's
or semi-Fowler's position will promote effective breathing and chest expansion.
A nurse is reviewing a client's laboratory results. Which of the following results should the nurse
report to the provider? - Magnesium 3 mEq/L
Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1
mEq/L. Therefore, the nurse should report this finding to the provider.
A nurse is participating in blood drive and is taking a donation from a client who has type O+
blood. The client asks the nurse what type of blood they can receive. Which of the following
statements should the nurse make? - "You can receive a blood donation from donors with type
O- and type O+ blood."
Rationale: Clients who have type O+ blood can only receive blood from donors who have type
O- or type O+ blood. Clients who have type O- blood are universal donors, meaning that anyone
can receive their blood, regardless of blood type.
, A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL
of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100
mL/hr. Which of the following amounts represents the client's intake over the last 4 hr? - 1,120
mL
Rationale: The client has taken in: 480 mL of water + 240 mL of coffee + (100 mL of fluids x 4
hr). 720 mL + 400 mL = 1,120 mL. The client's total intake in 4 hr is 1,120 mL.
A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing
metabolic alkalosis. The nurse should identify that this action is part of which of the following
steps of the nursing process? - Evaluation
Rationale: Reviewing the client's ABG values is part of the evaluation stage of the nursing
process. During the evaluation stage, the nurse should determine if the actions taken in the
implementation stage were successful in meeting the goals in the client's plan of care.
A nurse is receiving report on four clients. The nurse should identify that which of the following
clients may be experiencing hypomagnesemia? - A client who has vomited four times during the
last 8 hr.
Rationale: Nausea and vomiting are early manifestations of hypomagnesemia.
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following
actions should be the goal of treatment for a client? - Increase the carbon dioxide level.
Rationale: A state of respiratory alkalosis indicates that the client's carbon dioxide level is
currently below the expected reference range. The goal of treatment should be to raise the level
of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm
Hg.
A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed
red blood cells. The nurse should plan to infuse the blood over which of the following lengths of
time? - 4 hr
Rationale: Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for
circulatory overload, such as a client who has heart failure, a disorder in which compromised
cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be
administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart.
A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should
identify that which of the following findings is an indication that the treatment has been
effective? (Select all that apply.) - The client states their muscle spasms are absent.
The client denied being confused.
