ATI Fundamentals | Patient Safety & Fall Prevention Practice Pack
2026/2027 |Rationales
1. A nurse is assessing a client’s risk for falls using the Morse Fall Scale. Which of
the following factors is a component of this scale?
A. Age of the client
B. History of falling
C. Serum potassium level
D. Number of roommates
Answer: B
Rationale: The Morse Fall Scale includes history of falling, secondary diagnosis,
ambulatory aid, IV/saline lock, gait/transferring, and mental status.
2. When applying the RACE acronym during a fire, what does the ‘C’ stand for?
A. Carry patients out
B. Call for help
C. Clear the hallway
D. Confine the fire
Answer: D
Rationale: RACE stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. Confining
the fire involves closing doors and windows.
,3. A nurse is preparing to apply a wrist restraint to a client. Which of the
following actions should the nurse take?
A. Tie the restraint to the side rail
B. Ensure two fingers can fit under the restraint
C. Use a square knot to secure it
D. Apply the restraint as tightly as possible
Answer: B
Rationale: To prevent neurovascular injury, the nurse should ensure two fingers can fit
between the restraint and the client’s wrist and use a quick-release knot attached to the
bed frame.
4. Which of the following medications increases a client’s risk for falls?
A. Vitamin C
B. Furosemide
C. Acetaminophen
D. Stool softeners
Answer: B
Rationale: Loop diuretics like furosemide can cause orthostatic hypotension and increased
urgency/frequency of urination, both of which increase fall risk.
5. A nurse finds a client lying on the floor. After checking the client’s vital signs
and assessing for injuries, what is the nurse’s priority action?
A. Complete an incident report
B. Call the family
C. Notify the provider
D. Move the client back to bed
Answer: C
Rationale: Once the client is stable and assessed, the provider must be notified to evaluate
the client and provide further orders.
, 6. What is the maximum duration a provider’s initial order for restraints is valid
for an adult client?
A. 4 hours
B. 8 hours
C. 12 hours
D. 24 hours
Answer: A
Rationale: For adults 18 and older, the original order for behavioral restraints is limited to
4 hours, after which a new assessment and order are required.
7. A client is experiencing a tonic-clonic seizure. Which action should the nurse
take first?
A. Insert a padded tongue blade
B. Restrain the client’s limbs
C. Turn the client to a side-lying position
D. Administer oral glucose
Answer: C
Rationale: The priority is to maintain a patent airway and prevent aspiration by turning
the client to their side.
8. During a fire, which of the following is the correct sequence for using a fire
extinguisher?
A. Pass, Aim, Spray, Slide
B. Pull, Aim, Squeeze, Sweep
C. Pull, Activate, Send, Sweep
D. Push, Aim, Squeeze, Shake
Answer: B
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and
Sweep from side to side.
2026/2027 |Rationales
1. A nurse is assessing a client’s risk for falls using the Morse Fall Scale. Which of
the following factors is a component of this scale?
A. Age of the client
B. History of falling
C. Serum potassium level
D. Number of roommates
Answer: B
Rationale: The Morse Fall Scale includes history of falling, secondary diagnosis,
ambulatory aid, IV/saline lock, gait/transferring, and mental status.
2. When applying the RACE acronym during a fire, what does the ‘C’ stand for?
A. Carry patients out
B. Call for help
C. Clear the hallway
D. Confine the fire
Answer: D
Rationale: RACE stands for Rescue, Alarm, Confine, and Extinguish/Evacuate. Confining
the fire involves closing doors and windows.
,3. A nurse is preparing to apply a wrist restraint to a client. Which of the
following actions should the nurse take?
A. Tie the restraint to the side rail
B. Ensure two fingers can fit under the restraint
C. Use a square knot to secure it
D. Apply the restraint as tightly as possible
Answer: B
Rationale: To prevent neurovascular injury, the nurse should ensure two fingers can fit
between the restraint and the client’s wrist and use a quick-release knot attached to the
bed frame.
4. Which of the following medications increases a client’s risk for falls?
A. Vitamin C
B. Furosemide
C. Acetaminophen
D. Stool softeners
Answer: B
Rationale: Loop diuretics like furosemide can cause orthostatic hypotension and increased
urgency/frequency of urination, both of which increase fall risk.
5. A nurse finds a client lying on the floor. After checking the client’s vital signs
and assessing for injuries, what is the nurse’s priority action?
A. Complete an incident report
B. Call the family
C. Notify the provider
D. Move the client back to bed
Answer: C
Rationale: Once the client is stable and assessed, the provider must be notified to evaluate
the client and provide further orders.
, 6. What is the maximum duration a provider’s initial order for restraints is valid
for an adult client?
A. 4 hours
B. 8 hours
C. 12 hours
D. 24 hours
Answer: A
Rationale: For adults 18 and older, the original order for behavioral restraints is limited to
4 hours, after which a new assessment and order are required.
7. A client is experiencing a tonic-clonic seizure. Which action should the nurse
take first?
A. Insert a padded tongue blade
B. Restrain the client’s limbs
C. Turn the client to a side-lying position
D. Administer oral glucose
Answer: C
Rationale: The priority is to maintain a patent airway and prevent aspiration by turning
the client to their side.
8. During a fire, which of the following is the correct sequence for using a fire
extinguisher?
A. Pass, Aim, Spray, Slide
B. Pull, Aim, Squeeze, Sweep
C. Pull, Activate, Send, Sweep
D. Push, Aim, Squeeze, Shake
Answer: B
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and
Sweep from side to side.
