ATI Fundamentals: Patient Safety & Risk Reduction (Week 2 Study
Guide) 2026 |Rationales
1. Which action should a nurse take first when discovering a fire in a patient’s
room?
A. Activate the fire alarm system.
B. Rescue and move the patient to a safe location.
C. Attempt to extinguish the fire using a portable extinguisher.
D. Close all doors and windows in the immediate area.
Answer: B
Rationale: According to the RACE acronym, the priority action is Rescue. The nurse must
first ensure the safety of the patient before alarming, confining, or extinguishing.
2. When using a fire extinguisher, what does the ‘A’ in the acronym PASS stand
for?
A. Aim at the base of the fire.
B. Activate the trigger.
C. Adjust the nozzle.
D. Apply pressure to the handle.
Answer: A
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and
Sweep from side to side.
,3. A nurse is caring for a client who is at high risk for falls. Which of the
following is an appropriate safety intervention?
A. Keep all four side rails in the upright position.
B. Ensure the call light is within the client’s reach.
C. Instruct the client to wear their own silk socks for comfort.
D. Place the bedside table away from the bed to prevent clutter.
Answer: B
Rationale: Ensuring the call light is within reach allows the client to ask for assistance,
reducing the risk of unassisted ambulation and falls. Four side rails are considered a
restraint.
4. Which type of restraint requires a new prescription every 4 hours for an adult
client?
A. Medical-surgical restraints for wound care.
B. Mitt restraints used to prevent tube pulling.
C. A soft wrist restraint used for a confused elderly patient.
D. Behavioral restraints due to violent or self-destructive behavior.
Answer: D
Rationale: Prescriptions for behavioral restraints for adults (18+) must be renewed every
4 hours. Medical-surgical restraints typically require renewal every 24 hours.
5. A nurse is teaching a group of older adults about home safety. Which
instruction should be included?
A. Install throw rugs over slippery tile areas.
B. Use a 40-watt bulb in hallways to reduce glare.
C. Store frequently used items on the top shelf of the pantry.
D. Mark the edges of stairs with brightly colored tape.
Answer: D
, Rationale: Marking stair edges improves visibility and depth perception, helping to
prevent falls in the elderly.
6. What is the primary purpose of an incident report in a healthcare setting?
A. To provide a basis for disciplinary action against staff.
B. To document the event in the client’s permanent medical record.
C. To notify the facility’s legal counsel of potential lawsuits.
D. To identify factors that contribute to errors and improve safety.
Answer: D
Rationale: Incident reports are internal documents used for quality improvement and risk
management to prevent future occurrences. They are not part of the medical record.
7. Which infection control precaution should a nurse implement for a client with
Clostridium difficile (C. diff)?
A. Contact precautions.
B. Airborne precautions.
C. Droplet precautions.
D. Protective environment.
Answer: A
Rationale: C. diff is transmitted via direct contact. Contact precautions include gown and
gloves and require handwashing with soap and water (not sanitizer).
8. During a seizure, which of the following is the priority nursing action?
A. Insert a tongue blade into the client’s mouth.
B. Restrain the client’s limbs to prevent injury.
C. Turn the client to a side-lying position.
D. Administer oral anti-epileptic medication immediately.
Answer: C
Rationale: Positioning the client on their side helps maintain a patent airway and prevents
aspiration during a seizure.
Guide) 2026 |Rationales
1. Which action should a nurse take first when discovering a fire in a patient’s
room?
A. Activate the fire alarm system.
B. Rescue and move the patient to a safe location.
C. Attempt to extinguish the fire using a portable extinguisher.
D. Close all doors and windows in the immediate area.
Answer: B
Rationale: According to the RACE acronym, the priority action is Rescue. The nurse must
first ensure the safety of the patient before alarming, confining, or extinguishing.
2. When using a fire extinguisher, what does the ‘A’ in the acronym PASS stand
for?
A. Aim at the base of the fire.
B. Activate the trigger.
C. Adjust the nozzle.
D. Apply pressure to the handle.
Answer: A
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and
Sweep from side to side.
,3. A nurse is caring for a client who is at high risk for falls. Which of the
following is an appropriate safety intervention?
A. Keep all four side rails in the upright position.
B. Ensure the call light is within the client’s reach.
C. Instruct the client to wear their own silk socks for comfort.
D. Place the bedside table away from the bed to prevent clutter.
Answer: B
Rationale: Ensuring the call light is within reach allows the client to ask for assistance,
reducing the risk of unassisted ambulation and falls. Four side rails are considered a
restraint.
4. Which type of restraint requires a new prescription every 4 hours for an adult
client?
A. Medical-surgical restraints for wound care.
B. Mitt restraints used to prevent tube pulling.
C. A soft wrist restraint used for a confused elderly patient.
D. Behavioral restraints due to violent or self-destructive behavior.
Answer: D
Rationale: Prescriptions for behavioral restraints for adults (18+) must be renewed every
4 hours. Medical-surgical restraints typically require renewal every 24 hours.
5. A nurse is teaching a group of older adults about home safety. Which
instruction should be included?
A. Install throw rugs over slippery tile areas.
B. Use a 40-watt bulb in hallways to reduce glare.
C. Store frequently used items on the top shelf of the pantry.
D. Mark the edges of stairs with brightly colored tape.
Answer: D
, Rationale: Marking stair edges improves visibility and depth perception, helping to
prevent falls in the elderly.
6. What is the primary purpose of an incident report in a healthcare setting?
A. To provide a basis for disciplinary action against staff.
B. To document the event in the client’s permanent medical record.
C. To notify the facility’s legal counsel of potential lawsuits.
D. To identify factors that contribute to errors and improve safety.
Answer: D
Rationale: Incident reports are internal documents used for quality improvement and risk
management to prevent future occurrences. They are not part of the medical record.
7. Which infection control precaution should a nurse implement for a client with
Clostridium difficile (C. diff)?
A. Contact precautions.
B. Airborne precautions.
C. Droplet precautions.
D. Protective environment.
Answer: A
Rationale: C. diff is transmitted via direct contact. Contact precautions include gown and
gloves and require handwashing with soap and water (not sanitizer).
8. During a seizure, which of the following is the priority nursing action?
A. Insert a tongue blade into the client’s mouth.
B. Restrain the client’s limbs to prevent injury.
C. Turn the client to a side-lying position.
D. Administer oral anti-epileptic medication immediately.
Answer: C
Rationale: Positioning the client on their side helps maintain a patent airway and prevents
aspiration during a seizure.
