ATI NGN Case Studies: Fundamentals of
Nursing Practice Set 2024 (updated) and
with correct questions and answers
**1. A nurse is assessing an older adult client’s risk for falls. Which of the following assessments should
the nurse use to identify the client’s safety needs? (Select all that apply.)**
A. Pupil clarity
B. Visual fields
C. Visual acuity
D. Gait stability
, E. Muscle strength
**Answer:** B, C, D, E
**Rationale:** Visual field testing (B) and visual acuity (C) identify vision deficits that increase fall risk.
Assessing gait stability (D) and muscle strength (E) directly evaluates mobility and balance. Pupil clarity
(A) relates more to cataract identification than immediate safety risk .
**2. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell
transplant. Which of the following precautions should the nurse plan for this client?**
A. Place the client in a positive-pressure room
B. Make sure the client wears a mask when outside her room if there is construction in the area
C. Allow fresh flowers in the room
D. Use tap water for oral care
**Answer:** B
**Rationale:** This client is severely immunocompromised. A mask protects against airborne pathogens
during construction (B). Protective environments require *positive* pressure rooms (A is correct action
but negative pressure is for airborne isolation, not protection). Fresh flowers (C) harbor mold and
bacteria. Sterile water is needed for oral care, not tap water (D) .
**3. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist
restraints. Which of the following actions should the nurse take?**
A. Tie the restraints to the side rails
B. Pad the client’s wrist before applying the restraints
C. Apply the restraints tightly to ensure security
D. Secure the restraints with a quick-release knot to the bed frame
**Answer:** B
Nursing Practice Set 2024 (updated) and
with correct questions and answers
**1. A nurse is assessing an older adult client’s risk for falls. Which of the following assessments should
the nurse use to identify the client’s safety needs? (Select all that apply.)**
A. Pupil clarity
B. Visual fields
C. Visual acuity
D. Gait stability
, E. Muscle strength
**Answer:** B, C, D, E
**Rationale:** Visual field testing (B) and visual acuity (C) identify vision deficits that increase fall risk.
Assessing gait stability (D) and muscle strength (E) directly evaluates mobility and balance. Pupil clarity
(A) relates more to cataract identification than immediate safety risk .
**2. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell
transplant. Which of the following precautions should the nurse plan for this client?**
A. Place the client in a positive-pressure room
B. Make sure the client wears a mask when outside her room if there is construction in the area
C. Allow fresh flowers in the room
D. Use tap water for oral care
**Answer:** B
**Rationale:** This client is severely immunocompromised. A mask protects against airborne pathogens
during construction (B). Protective environments require *positive* pressure rooms (A is correct action
but negative pressure is for airborne isolation, not protection). Fresh flowers (C) harbor mold and
bacteria. Sterile water is needed for oral care, not tap water (D) .
**3. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist
restraints. Which of the following actions should the nurse take?**
A. Tie the restraints to the side rails
B. Pad the client’s wrist before applying the restraints
C. Apply the restraints tightly to ensure security
D. Secure the restraints with a quick-release knot to the bed frame
**Answer:** B
