ATI Fundamentals Proctored Exam Study Guide 3 -Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Determine client's risk factors. This is crucial to assess the client's current health status, identify potential health risks, and develop a personalized health promotion plan. By understanding the client's risk factors such as sexual behaviors, substance use, family history, and lifestyle habits, the nurse can tailor education and interventions to promote health and prevent diseases specific to the client's needs.

A: Measuring vital signs is important but does not directly address health promotion and disease prevention strategies in this context.
B: Encouraging HIV screening is important, but it focuses on a specific test rather than a comprehensive assessment of risk factors.
D: Instructing the client to use condoms is a good preventive measure, but determining risk factors provides a broader picture for a more comprehensive approach.

Correct Answer: B,C,D

Rationale: The correct answers are B, C, and D. B: Placing blankets over clients in beds ensures they are protected from debris. C: Moving beds away from windows reduces the risk of glass injuries. D: Drawing shades and closing drapes can prevent glass from shattering and causing harm. A: Opening doors to client rooms can increase the risk of debris entering rooms. E: Relocating ambulatory clients back to rooms may expose them to more danger in confined spaces during a tornado.

Correct Answer: A,B,D

Rationale: The correct answers are A, B, and D. At 6 months, typical gross motor development includes rolling from back to front (
A), bearing weight on legs (
B), and sitting unsupported (
D). Rolling helps strengthen core muscles and coordination. Bearing weight on legs is a precursor to standing and walking. Sitting unsupported demonstrates good head and trunk control.

Choices C and E are not typically expected by 9 months. Walking holding onto furniture (
C) usually occurs around 9-12 months, and sitting down from a standing position (E) is a more complex skill that emerges later.

Correct Answer: D

Rationale: The correct answer is D: Assess client's ability to help with transfer. This is the priority action because it ensures the safety of the client during the transfer process. By assessing the client's ability to help, the nurse can determine the level of assistance needed and prevent any potential injuries or accidents.


Choice A is incorrect because obtaining a walker may not be necessary if the client is able to transfer without it.


Choice B is incorrect as calling for additional personnel should not be the immediate priority without first assessing the client's ability to help with the transfer.


Choice C is incorrect as using a transfer belt assumes the client needs assistance, which may not be the case if the client is able to transfer independently.

Overall, assessing the client's ability first allows for a tailored and safe approach to transferring the client back to bed.

Correct Answer: B

Rationale: The correct answer is B. Going to the nurses' station for assistance may cause a delay in providing immediate care to the client with seizures. The nurse should stay with the client to ensure safety and monitor for complications. Placing the client on their side (
A) helps prevent aspiration, administering meds as prescribed (
C) is essential for seizure management, and being prepared to insert an airway (
D) is a crucial step in case of respiratory distress. Other choices were left blank.