ATI Fundamentals Proctored Exam 2020
/ 2021 | ATI Fundamentals Proctored
Exam_100% Correct Answers
Section 1: Safety & Restraints (Questions 1–12)
1. A nurse is caring for an older adult client who is at risk for falls. Which of the following
actions should the nurse take first?
A. Place a fall-risk wristband on the client
B. Complete a fall-risk assessment
C. Raise all four side rails
D. Move the client to a room near the nurses' station
Correct Answer: B
Rationale: Assessment is the first step of the nursing process. Before implementing any fall-
prevention intervention, the nurse must identify the client's specific risk factors using a
validated tool. Wristbands (A), side rails (C), and room assignment (D) are interventions that
should follow assessment. Raising all four side rails is also a restraint and requires a provider
order.
2. A nurse is applying a vest restraint to a client who is confused and attempting to climb out
of bed. Which of the following actions is appropriate? (SATA)
A. Secure the restraint to the bed frame using a quick-release knot
B. Ensure two fingers can fit between the restraint and the client's chest
C. Tie the restraint straps to the side rails
D. Remove the restraint every 2 hours to assess skin and circulation
E. Obtain a provider's order within 1 hour of application in an emergency
Correct Answers: A, B, D, E
Rationale: Restraint straps must be attached to the bed frame (not side rails) with a quick-
release knot (A). Two fingers should fit under the vest to prevent restriction of breathing (B).
Restraints must be removed, the client assessed, and circulation/skin checked at least every 2
hours (D). In an emergency, a restraint may be applied before the order but the provider must
,be notified and an order obtained within 1 hour (E). Tying to side rails (C) is incorrect because
movement of the rails can injure the client and it impedes quick release.
3. A nurse is evaluating the effectiveness of a client's restraint. Which of the following findings
indicates the restraint is effective?
A. The client is sleeping quietly
B. The client's agitation has decreased and the client is no longer attempting to remove needed
devices
C. The client states, "I hate this thing"
D. The client's family has agreed to stay at the bedside
Correct Answer: B
Rationale: The purpose of a restraint is to protect the client from harm, not to sedate or
punish. Effectiveness is measured by whether the dangerous behavior (e.g., pulling at an IV or
attempting to get up unassisted) has stopped. Sleeping (A) may simply reflect fatigue or
sedation. A client's dislike of the restraint (C) does not measure effectiveness. Family presence
(D) is a helpful alternative but does not by itself indicate restraint effectiveness.
4. Which of the following clients requires the nurse to use a mechanical lift for transfer?
A. A client who had a total knee replacement 2 days ago
B. A client who is 3 days postoperative and can bear weight
C. A client who is morbidly obese and cannot assist with transfer
D. A client who is confused but ambulatory with a walker
Correct Answer: C
Rationale: A mechanical lift is indicated for clients who cannot bear weight or assist with
the transfer and who pose a risk of injury to staff if manually lifted. A client who is morbidly
obese and non-weight-bearing is the classic indication. Clients who can bear weight (A, B) or
ambulate (D) do not require a lift.
5. A nurse is teaching a client about using a cane. Which of the following instructions is
correct?
A. "Hold the cane on the weaker side and move it with the weaker leg."
B. "Hold the cane on the stronger side and move it forward with the weaker leg."
,C. "Hold the cane on the weaker side and move it with the stronger leg."
D. "Hold the cane on the stronger side and move it with the stronger leg."
Correct Answer: B
Rationale: A cane is held on the stronger (unaffected) side to provide a wide base of
support and to shift weight away from the weaker side. The cane is advanced at the same time
as the weaker leg, then the stronger leg moves forward. Options A, C, and D describe incorrect
patterns that increase the risk of falls.
6. A nurse is implementing seizure precautions for a client with a new diagnosis of epilepsy.
Which of the following should the nurse include? (SATA)
A. Pad the side rails of the bed
B. Keep suction equipment and oxygen at the bedside
C. Place a tongue blade at the bedside for use during a seizure
D. Raise the bed to the lowest position
E. Keep the bed in a high side-rail position when the client is unattended
Correct Answers: A, B, D
Rationale: Seizure precautions include padding side rails (A), having suction and oxygen
immediately available (B), and keeping the bed low (D). Tongue blades (C) should never be
placed in a client's mouth because of the risk of breaking teeth, aspiration, or injuring the nurse.
If the bed is unattended with side rails up (E), the client could be injured; the bed should be low
and the call light within reach.
7. A nurse is caring for a client who is receiving continuous oxygen therapy and is confused.
Which of the following is the priority safety intervention?
A. Apply wrist restraints to prevent removal of the nasal cannula
B. Post a "no smoking" sign and ensure the client is not near open flames
C. Increase the oxygen flow rate to keep the client calm
D. Restrict family visitation
Correct Answer: B
Rationale: Oxygen is a fire hazard. The priority safety intervention is to eliminate ignition
sources — no smoking, no open flames, and no electrical equipment that could spark.
Restraints (A) are a last resort and require an order. Increasing oxygen (C) is not a safety
, intervention and requires a provider order. Restricting visitation (D) is not indicated and violates
client rights.
8. A nurse is assessing a client's home for safety hazards. Which of the following findings
should the nurse identify as the highest risk for falls?
A. Loose area rugs in the hallway
B. A pet cat in the home
C. A bathroom without grab bars
D. A bedroom on the second floor
Correct Answer: A
Rationale: Loose rugs are a well-documented environmental fall hazard and can cause a
client to slip or trip. While grab bars (C) and stairs (D) are also risks, a loose rug on a walking
surface presents an immediate, high-probability hazard. A pet (B) can be a trip hazard but is less
consistently dangerous than a loose rug.
9. A nurse is completing a home safety assessment for an older adult client. Which of the
following recommendations should the nurse make to prevent falls in the bathroom? (SATA)
A. Install grab bars in the shower and beside the toilet
B. Use a raised toilet seat
C. Place a nonskid mat in the tub
D. Use a bath chair or shower stool
E. Keep the bathroom door locked during use
Correct Answers: A, B, C, D
Rationale: Grab bars (A), a raised toilet seat (B), a nonskid mat (C), and a shower chair (D) all
reduce fall risk in the bathroom. Locking the door (E) is unsafe because it delays emergency
assistance if the client falls.
10. A nurse is caring for a client who is postoperative and has a prescription for a sequential
compression device (SCD). The client asks why the device is needed. Which of the following
responses should the nurse make?
A. "It keeps your legs warm while you are in bed."
B. "It helps prevent blood clots by increasing circulation in your legs."
/ 2021 | ATI Fundamentals Proctored
Exam_100% Correct Answers
Section 1: Safety & Restraints (Questions 1–12)
1. A nurse is caring for an older adult client who is at risk for falls. Which of the following
actions should the nurse take first?
A. Place a fall-risk wristband on the client
B. Complete a fall-risk assessment
C. Raise all four side rails
D. Move the client to a room near the nurses' station
Correct Answer: B
Rationale: Assessment is the first step of the nursing process. Before implementing any fall-
prevention intervention, the nurse must identify the client's specific risk factors using a
validated tool. Wristbands (A), side rails (C), and room assignment (D) are interventions that
should follow assessment. Raising all four side rails is also a restraint and requires a provider
order.
2. A nurse is applying a vest restraint to a client who is confused and attempting to climb out
of bed. Which of the following actions is appropriate? (SATA)
A. Secure the restraint to the bed frame using a quick-release knot
B. Ensure two fingers can fit between the restraint and the client's chest
C. Tie the restraint straps to the side rails
D. Remove the restraint every 2 hours to assess skin and circulation
E. Obtain a provider's order within 1 hour of application in an emergency
Correct Answers: A, B, D, E
Rationale: Restraint straps must be attached to the bed frame (not side rails) with a quick-
release knot (A). Two fingers should fit under the vest to prevent restriction of breathing (B).
Restraints must be removed, the client assessed, and circulation/skin checked at least every 2
hours (D). In an emergency, a restraint may be applied before the order but the provider must
,be notified and an order obtained within 1 hour (E). Tying to side rails (C) is incorrect because
movement of the rails can injure the client and it impedes quick release.
3. A nurse is evaluating the effectiveness of a client's restraint. Which of the following findings
indicates the restraint is effective?
A. The client is sleeping quietly
B. The client's agitation has decreased and the client is no longer attempting to remove needed
devices
C. The client states, "I hate this thing"
D. The client's family has agreed to stay at the bedside
Correct Answer: B
Rationale: The purpose of a restraint is to protect the client from harm, not to sedate or
punish. Effectiveness is measured by whether the dangerous behavior (e.g., pulling at an IV or
attempting to get up unassisted) has stopped. Sleeping (A) may simply reflect fatigue or
sedation. A client's dislike of the restraint (C) does not measure effectiveness. Family presence
(D) is a helpful alternative but does not by itself indicate restraint effectiveness.
4. Which of the following clients requires the nurse to use a mechanical lift for transfer?
A. A client who had a total knee replacement 2 days ago
B. A client who is 3 days postoperative and can bear weight
C. A client who is morbidly obese and cannot assist with transfer
D. A client who is confused but ambulatory with a walker
Correct Answer: C
Rationale: A mechanical lift is indicated for clients who cannot bear weight or assist with
the transfer and who pose a risk of injury to staff if manually lifted. A client who is morbidly
obese and non-weight-bearing is the classic indication. Clients who can bear weight (A, B) or
ambulate (D) do not require a lift.
5. A nurse is teaching a client about using a cane. Which of the following instructions is
correct?
A. "Hold the cane on the weaker side and move it with the weaker leg."
B. "Hold the cane on the stronger side and move it forward with the weaker leg."
,C. "Hold the cane on the weaker side and move it with the stronger leg."
D. "Hold the cane on the stronger side and move it with the stronger leg."
Correct Answer: B
Rationale: A cane is held on the stronger (unaffected) side to provide a wide base of
support and to shift weight away from the weaker side. The cane is advanced at the same time
as the weaker leg, then the stronger leg moves forward. Options A, C, and D describe incorrect
patterns that increase the risk of falls.
6. A nurse is implementing seizure precautions for a client with a new diagnosis of epilepsy.
Which of the following should the nurse include? (SATA)
A. Pad the side rails of the bed
B. Keep suction equipment and oxygen at the bedside
C. Place a tongue blade at the bedside for use during a seizure
D. Raise the bed to the lowest position
E. Keep the bed in a high side-rail position when the client is unattended
Correct Answers: A, B, D
Rationale: Seizure precautions include padding side rails (A), having suction and oxygen
immediately available (B), and keeping the bed low (D). Tongue blades (C) should never be
placed in a client's mouth because of the risk of breaking teeth, aspiration, or injuring the nurse.
If the bed is unattended with side rails up (E), the client could be injured; the bed should be low
and the call light within reach.
7. A nurse is caring for a client who is receiving continuous oxygen therapy and is confused.
Which of the following is the priority safety intervention?
A. Apply wrist restraints to prevent removal of the nasal cannula
B. Post a "no smoking" sign and ensure the client is not near open flames
C. Increase the oxygen flow rate to keep the client calm
D. Restrict family visitation
Correct Answer: B
Rationale: Oxygen is a fire hazard. The priority safety intervention is to eliminate ignition
sources — no smoking, no open flames, and no electrical equipment that could spark.
Restraints (A) are a last resort and require an order. Increasing oxygen (C) is not a safety
, intervention and requires a provider order. Restricting visitation (D) is not indicated and violates
client rights.
8. A nurse is assessing a client's home for safety hazards. Which of the following findings
should the nurse identify as the highest risk for falls?
A. Loose area rugs in the hallway
B. A pet cat in the home
C. A bathroom without grab bars
D. A bedroom on the second floor
Correct Answer: A
Rationale: Loose rugs are a well-documented environmental fall hazard and can cause a
client to slip or trip. While grab bars (C) and stairs (D) are also risks, a loose rug on a walking
surface presents an immediate, high-probability hazard. A pet (B) can be a trip hazard but is less
consistently dangerous than a loose rug.
9. A nurse is completing a home safety assessment for an older adult client. Which of the
following recommendations should the nurse make to prevent falls in the bathroom? (SATA)
A. Install grab bars in the shower and beside the toilet
B. Use a raised toilet seat
C. Place a nonskid mat in the tub
D. Use a bath chair or shower stool
E. Keep the bathroom door locked during use
Correct Answers: A, B, C, D
Rationale: Grab bars (A), a raised toilet seat (B), a nonskid mat (C), and a shower chair (D) all
reduce fall risk in the bathroom. Locking the door (E) is unsafe because it delays emergency
assistance if the client falls.
10. A nurse is caring for a client who is postoperative and has a prescription for a sequential
compression device (SCD). The client asks why the device is needed. Which of the following
responses should the nurse make?
A. "It keeps your legs warm while you are in bed."
B. "It helps prevent blood clots by increasing circulation in your legs."
