ATI HEALTH ASSESSMENT FINAL EXAM 3 LATEST VERSIONS (VERSION A, B AND C)
NEWEST 2025/2026 ACTUAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS PLUS RATIONALES
Question 1
When using a Snellen chart to test a patient's visual acuity, how far should the patient stand
from the chart?
A) 14 inches
B) 20 inches
C) 14 feet
D) 20 feet
E) 10 feet
Correct Answer: D) 20 feet
Rationale: The standard distance for a Snellen eye chart assessment is 20 feet to accurately
measure distance vision.
Question 2
A nurse is assessing a patient's near vision using a Rosenbaum chart. What is the correct
distance to hold the chart from the patient's eyes?
A) 20 feet
B) 14 inches
C) 20 inches
D) 6 feet
E) 10 inches
Correct Answer: B) 14 inches
Rationale: The Rosenbaum chart is designed to test near vision and should be held at a
distance of 14 inches from the patient's face.
Question 3
Which of the following is NOT considered a factor that can affect a patient's ability to protect
themselves?
A) Age
B) Mobility
,C) Blood type
D) Emotional state
E) Cognitive and sensory awareness
Correct Answer: C) Blood type
Rationale: While age, mobility, cognitive awareness, emotional state, ability to communicate,
and lifestyle are all factors that affect patient safety, blood type is not a contributing factor.
Question 4
A nurse is assessing a patient's fall risk. Which condition would increase a patient's risk for falls?
A) Acute visual acuity
B) Responding well to physical therapy
C) Continent of urine
D) Generalized weakness
E) Normal gait and balance
Correct Answer: D) Generalized weakness
Rationale: Generalized weakness, along with decreased visual acuity, urinary frequency, and
gait/balance problems, is a significant risk factor for falls.
Question 5
Which of the following is an essential component of seizure precautions?
A) Having restraints readily available at the bedside
B) Ensuring a tongue depressor is taped to the head of the bed
C) Having oxygen and suction equipment at the bedside
D) Keeping the side rails down at all times
E) Restraining the patient's limbs during the seizure
Correct Answer: C) Having oxygen and suction equipment at the bedside
Rationale: Seizure precautions require having equipment ready for rapid intervention to
maintain airway patency, including oxygen, suction, and an oral airway.
Question 6
A nurse is educating a patient with orthostatic hypotension on how to prevent falls. Which
,instruction is most appropriate?
A) "Jump out of bed quickly in the morning to get your circulation moving."
B) "You should try to walk immediately after standing up."
C) "Sit on the side of the bed for a few seconds before you stand up."
D) "It's best to keep your legs crossed when you are sitting."
E) "Avoid drinking fluids to prevent dizziness."
Correct Answer: C) "Sit on the side of the bed for a few seconds before you stand up."
Rationale: To prevent a sudden drop in blood pressure and subsequent dizziness, patients
with orthostatic hypotension should change positions slowly, including sitting at the bedside
for a few moments before standing.
Question 7
Under what circumstance is it appropriate for a nurse to apply restraints?
A) As a first-line intervention for a confused patient
B) For the convenience of the nursing staff
C) When all other less restrictive measures have failed
D) Whenever a patient refuses to take their medication
E) If a family member requests them for an agitated patient
Correct Answer: C) When all other less restrictive measures have failed
Rationale: Restraints are a last resort and should only be used after attempting and
documenting the failure of other measures like reorientation, family presence, or diversional
activities.
Question 8
A provider's prescription for restraints must include all of the following EXCEPT:
A) The reason for the restraints
B) The type of restraints to be used
C) The location of the restraints
D) The patient's preferred comfort measures
E) The duration for the use of the restraints
Correct Answer: D) The patient's preferred comfort measures
, Rationale: A valid restraint prescription must specify the reason, type, location, duration, and
behaviors that warrant their use. Comfort measures are part of the nursing care plan but not
the prescription itself.
Question 9
What is the maximum duration a single restraint prescription for an adult is valid before it
requires renewal?
A) 1 hour
B) 4 hours
C) 8 hours
D) 12 hours
E) 24 hours
Correct Answer: B) 4 hours
Rationale: For an adult, a restraint prescription is only valid for up to 4 hours. Providers may
renew the prescription, but only for a maximum of 24 consecutive hours.
Question 10
A nurse applies restraints in an emergency situation to prevent immediate harm to the patient
and others. What is the nurse's next priority action?
A) Document the event in the patient's chart at the end of the shift
B) Obtain a prescription from the provider as soon as possible, usually within 1 hour
C) Ask a family member to sign a consent form
D) Assess the patient's skin integrity in 2 hours
E) Offer the patient food and fluids
Correct Answer: B) Obtain a prescription from the provider as soon as possible, usually within
1 hour
Rationale: When restraints are applied in an emergency, the nurse must obtain a provider's
order promptly (typically within one hour) to ensure the intervention is medically justified
and meets legal requirements.
NEWEST 2025/2026 ACTUAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS PLUS RATIONALES
Question 1
When using a Snellen chart to test a patient's visual acuity, how far should the patient stand
from the chart?
A) 14 inches
B) 20 inches
C) 14 feet
D) 20 feet
E) 10 feet
Correct Answer: D) 20 feet
Rationale: The standard distance for a Snellen eye chart assessment is 20 feet to accurately
measure distance vision.
Question 2
A nurse is assessing a patient's near vision using a Rosenbaum chart. What is the correct
distance to hold the chart from the patient's eyes?
A) 20 feet
B) 14 inches
C) 20 inches
D) 6 feet
E) 10 inches
Correct Answer: B) 14 inches
Rationale: The Rosenbaum chart is designed to test near vision and should be held at a
distance of 14 inches from the patient's face.
Question 3
Which of the following is NOT considered a factor that can affect a patient's ability to protect
themselves?
A) Age
B) Mobility
,C) Blood type
D) Emotional state
E) Cognitive and sensory awareness
Correct Answer: C) Blood type
Rationale: While age, mobility, cognitive awareness, emotional state, ability to communicate,
and lifestyle are all factors that affect patient safety, blood type is not a contributing factor.
Question 4
A nurse is assessing a patient's fall risk. Which condition would increase a patient's risk for falls?
A) Acute visual acuity
B) Responding well to physical therapy
C) Continent of urine
D) Generalized weakness
E) Normal gait and balance
Correct Answer: D) Generalized weakness
Rationale: Generalized weakness, along with decreased visual acuity, urinary frequency, and
gait/balance problems, is a significant risk factor for falls.
Question 5
Which of the following is an essential component of seizure precautions?
A) Having restraints readily available at the bedside
B) Ensuring a tongue depressor is taped to the head of the bed
C) Having oxygen and suction equipment at the bedside
D) Keeping the side rails down at all times
E) Restraining the patient's limbs during the seizure
Correct Answer: C) Having oxygen and suction equipment at the bedside
Rationale: Seizure precautions require having equipment ready for rapid intervention to
maintain airway patency, including oxygen, suction, and an oral airway.
Question 6
A nurse is educating a patient with orthostatic hypotension on how to prevent falls. Which
,instruction is most appropriate?
A) "Jump out of bed quickly in the morning to get your circulation moving."
B) "You should try to walk immediately after standing up."
C) "Sit on the side of the bed for a few seconds before you stand up."
D) "It's best to keep your legs crossed when you are sitting."
E) "Avoid drinking fluids to prevent dizziness."
Correct Answer: C) "Sit on the side of the bed for a few seconds before you stand up."
Rationale: To prevent a sudden drop in blood pressure and subsequent dizziness, patients
with orthostatic hypotension should change positions slowly, including sitting at the bedside
for a few moments before standing.
Question 7
Under what circumstance is it appropriate for a nurse to apply restraints?
A) As a first-line intervention for a confused patient
B) For the convenience of the nursing staff
C) When all other less restrictive measures have failed
D) Whenever a patient refuses to take their medication
E) If a family member requests them for an agitated patient
Correct Answer: C) When all other less restrictive measures have failed
Rationale: Restraints are a last resort and should only be used after attempting and
documenting the failure of other measures like reorientation, family presence, or diversional
activities.
Question 8
A provider's prescription for restraints must include all of the following EXCEPT:
A) The reason for the restraints
B) The type of restraints to be used
C) The location of the restraints
D) The patient's preferred comfort measures
E) The duration for the use of the restraints
Correct Answer: D) The patient's preferred comfort measures
, Rationale: A valid restraint prescription must specify the reason, type, location, duration, and
behaviors that warrant their use. Comfort measures are part of the nursing care plan but not
the prescription itself.
Question 9
What is the maximum duration a single restraint prescription for an adult is valid before it
requires renewal?
A) 1 hour
B) 4 hours
C) 8 hours
D) 12 hours
E) 24 hours
Correct Answer: B) 4 hours
Rationale: For an adult, a restraint prescription is only valid for up to 4 hours. Providers may
renew the prescription, but only for a maximum of 24 consecutive hours.
Question 10
A nurse applies restraints in an emergency situation to prevent immediate harm to the patient
and others. What is the nurse's next priority action?
A) Document the event in the patient's chart at the end of the shift
B) Obtain a prescription from the provider as soon as possible, usually within 1 hour
C) Ask a family member to sign a consent form
D) Assess the patient's skin integrity in 2 hours
E) Offer the patient food and fluids
Correct Answer: B) Obtain a prescription from the provider as soon as possible, usually within
1 hour
Rationale: When restraints are applied in an emergency, the nurse must obtain a provider's
order promptly (typically within one hour) to ensure the intervention is medically justified
and meets legal requirements.
