Fall prevention NCLEX-RN Practice Questions

Fall Prevention NCLEX-RN Practice Questions help you master safety strategies fundamental to nursing care. Falls are among the most common and preventable adverse events across inpatient, long-term, and community settings. These questions target practical, high-yield interventions: risk assessment tools (like Morse Fall Scale), medication-related fall risks, environmental modifications, transfer and ambulation techniques, restraint alternatives, and post-fall priorities. You’ll practice prioritizing care for older adults, patients with delirium or orthostatic hypotension, and those on high-risk medications (opioids, sedatives, diuretics, antihypertensives, anticoagulants). Each scenario reflects real NCLEX-level decision-making to strengthen clinical judgment. Use this set to refine swift, safe responses and to integrate patient-centered education that prevents injury and promotes mobility and independence.

Q1. A hospitalized older adult with delirium is identified as high risk for falls, especially at night. Which initial intervention is most effective to reduce fall risk?

• Implement hourly rounding with scheduled toileting, pain assessment, and offer of assistance
• Raise all four side rails to prevent the patient from getting out of bed
• Apply bilateral wrist restraints during nighttime hours
• Encourage family to bring soft slippers from home

Correct Answer: Implement hourly rounding with scheduled toileting, pain assessment, and offer of assistance

Q2. Which medication most directly increases a patient’s risk for falls due to sedation and impaired coordination?

• Lorazepam
• Metoprolol
• Acetaminophen
• Famotidine

Correct Answer: Lorazepam

Q3. A patient falls in the hallway. What is the nurse’s priority action?

• Assist the patient back to bed and obtain vital signs
• Assess the patient for injury before moving, including a focused neuro and musculoskeletal check
• Notify the provider immediately and request imaging
• Complete an incident report and file it in the chart

Correct Answer: Assess the patient for injury before moving, including a focused neuro and musculoskeletal check

Q4. The nurse is teaching an older adult with orthostatic hypotension how to prevent falls when getting out of bed. Which instruction is best?

• Sit at the edge of the bed for 1–2 minutes before standing, then rise slowly
• Cross your legs and stand up quickly to stabilize blood pressure
• Wear loose, backless footwear for comfort
• Drink extra fluids even if on fluid restriction

Correct Answer: Sit at the edge of the bed for 1–2 minutes before standing, then rise slowly

Q5. Which home modification best reduces fall risk for an anticoagulated older adult living alone?

• Remove throw rugs and clutter from walking paths
• Wax hardwood floors for easier cleaning
• Store frequently used items on high shelves
• Use dim lighting to promote sleep

Correct Answer: Remove throw rugs and clutter from walking paths

Q6. When assisting a weak patient to ambulate with a gait belt, which technique is correct to reduce falls?

• Hold the patient’s forearms tightly to guide movement
• Place the belt over the chest so it doesn’t slip at the waist
• Stand slightly behind and on the weak side, grasping the gait belt at the back with an underhand grip
• Walk directly in front of the patient to pull them forward

Correct Answer: Stand slightly behind and on the weak side, grasping the gait belt at the back with an underhand grip

Q7. For which patient is a bed-exit alarm most appropriate?

• A fully oriented patient who requests assistance before ambulating
• A patient with delirium who repeatedly attempts to get out of bed unassisted
• A patient on bed rest with continuous ECG monitoring
• A patient awaiting discharge who ambulates independently

Correct Answer: A patient with delirium who repeatedly attempts to get out of bed unassisted

Q8. Which assessment finding indicates the highest risk for falls?

• Wears corrective eyeglasses
• Age 68 years
• Uses a cane for long distances
• History of a fall within the past 3 months

Correct Answer: History of a fall within the past 3 months

Q9. During purposeful hourly rounding, which “4 Ps” reduce fall risk most effectively?

• Pain, Position, Potty, Possessions
• Pulse, Perfusion, Posture, Preventatives
• Plan, Practice, Prevent, Protect
• Perception, Panic, Priority, Pathway

Correct Answer: Pain, Position, Potty, Possessions

Q10. Which is the best restraint alternative for a confused patient at high risk of falls?

• Raise all four side rails at night
• Administer a sedative to keep the patient resting
• Use a low-low bed with a floor mat and activate the bed alarm
• Tie the patient in a chair with a soft belt

Correct Answer: Use a low-low bed with a floor mat and activate the bed alarm

Q11. Which statement about side rails is accurate?

• Raising all four side rails is a safe way to prevent falls
• Keeping all rails down always decreases falls
• Raising all four side rails is considered a restraint and may increase fall risk
• Half rails are always non-restrictive and risk free

Correct Answer: Raising all four side rails is considered a restraint and may increase fall risk

Q12. A patient on a new opioid PCA is at increased risk for falls. Which instruction is most important?

• Call for assistance before getting out of bed or to the bathroom
• Ambulate independently to maintain mobility
• Turn off the PCA when feeling drowsy
• Drink coffee to offset drowsiness before walking

Correct Answer: Call for assistance before getting out of bed or to the bathroom

Q13. To reduce bathroom-related falls in a patient with urge incontinence, which toileting schedule is best while awake?

• Every 4 hours
• Every 2 hours
• Only on request
• Every shift

Correct Answer: Every 2 hours

Q14. A visually impaired patient is being discharged home. Which recommendation best reduces fall risk?

• Use high-contrast tape on stair edges and install grab bars in the bathroom
• Keep curtains closed during the day to reduce glare
• Use area rugs to cushion footsteps
• Store frequently used items on top shelves

Correct Answer: Use high-contrast tape on stair edges and install grab bars in the bathroom

Q15. What is the correct instruction for using a standard walker to minimize falls?

• Step forward with the stronger leg first, then move the walker
• Advance the walker, keep all four legs on the ground, step into the walker with the weaker leg first
• Place the walker far ahead for longer steps
• Look down at the feet constantly while walking

Correct Answer: Advance the walker, keep all four legs on the ground, step into the walker with the weaker leg first

Q16. Which environmental strategy best reduces fall risk for a hospitalized patient with acute delirium?

• Keep the room dark and quiet at all times
• Move the patient to different rooms to stimulate orientation
• Provide a quiet, well-lit room with a clock/calendar and frequent reorientation
• Administer sedatives routinely to ensure sleep

Correct Answer: Provide a quiet, well-lit room with a clock/calendar and frequent reorientation

Q17. On the Morse Fall Scale, which score indicates high fall risk requiring bundled interventions?

• ≥15
• ≥25
• ≥45
• ≥65

Correct Answer: ≥45

Q18. Which footwear is safest for reducing inpatient fall risk?

• Loose, backless slippers
• Open-toe sandals
• Non-skid socks with holes for ventilation
• Well-fitting, closed-back shoes with non-skid soles

Correct Answer: Well-fitting, closed-back shoes with non-skid soles

Q19. A patient just started an antihypertensive and reports dizziness when standing. Which nursing action best prevents falls?

• Encourage brisk standing to acclimate quickly
• Have the patient dangle legs at the bedside and assess for dizziness before ambulating
• Stop ambulation until medication is discontinued
• Increase the dose to shorten adjustment time

Correct Answer: Have the patient dangle legs at the bedside and assess for dizziness before ambulating

Q20. Which unit-level strategy has the strongest evidence for reducing inpatient falls during night shifts?

• Hourly rounding with 4 Ps
• Rounding only when the call light is activated
• Every 4-hour rounding to minimize disturbances
• Bed alarms without rounding

Correct Answer: Hourly rounding with 4 Ps

Q21. A confused patient with a recent hip fracture needs bed-level fall prevention. What is the best option?

• Standard-height bed with four side rails up
• Low-low bed with a floor mat and bed alarm activated
• Bilateral wrist restraints to prevent getting up
• Chair alarms only during meals

Correct Answer: Low-low bed with a floor mat and bed alarm activated

Q22. Which documentation after a patient fall is correct?

• “Incident report completed and filed” noted in the progress note
• Objective assessment findings, interventions, notifications, and patient response documented in the medical record
• “Patient fell due to noncompliance” with subjective attribution
• Names of staff at fault recorded in the progress note

Correct Answer: Objective assessment findings, interventions, notifications, and patient response documented in the medical record

Q23. Which patient is the best candidate for hip protectors to reduce injury from potential falls?

• Young athlete with a sprained ankle
• Older adult with osteoporosis and recurrent falls
• Patient with controlled type 2 diabetes and steady gait
• Postpartum patient without mobility issues

Correct Answer: Older adult with osteoporosis and recurrent falls

Q24. Which medication combination most increases fall risk due to sedation and anticholinergic effects?

• Vitamin D and calcium
• ACE inhibitor alone
• Statin at bedtime
• Benzodiazepine with diphenhydramine

Correct Answer: Benzodiazepine with diphenhydramine

Q25. A patient with insulin-treated diabetes has had near-falls related to hypoglycemia. Which instruction best reduces fall risk?

• Skip insulin doses when not eating
• Report dizziness, sweating, or trembling and check blood glucose before ambulating if symptomatic
• Restrict carbohydrates to avoid hypoglycemia
• Increase insulin dose at bedtime to improve control

Correct Answer: Report dizziness, sweating, or trembling and check blood glucose before ambulating if symptomatic

Q26. Which inpatient bathroom modification best prevents slips and falls?

• Place a small throw rug near the sink for comfort
• Install grab bars and use a non-skid bath/shower mat
• Turn off the bathroom night light to promote rest
• Store the call light on the counter to keep cords off the floor

Correct Answer: Install grab bars and use a non-skid bath/shower mat

Q27. A patient with dementia wanders and attempts to leave the unit. What is the most appropriate fall-prevention strategy?

• Restrain the patient in a geri-chair during the day
• Place the patient near the nurses’ station, initiate elopement precautions, and use a wearable alarm sensor
• Turn off the bed alarm to reduce noise
• Keep the door closed and lights off

Correct Answer: Place the patient near the nurses’ station, initiate elopement precautions, and use a wearable alarm sensor

Q28. An anticoagulated patient falls and hits their head but denies symptoms. What is the priority action?

• Assist back to bed and reassess in 4 hours
• Notify the provider immediately and initiate frequent neurological checks
• Apply ice and continue routine care
• Encourage oral fluids to prevent hypotension

Correct Answer: Notify the provider immediately and initiate frequent neurological checks

Q29. A competent patient refuses a bed alarm. What is the nurse’s best response?

• Activate the bed alarm regardless for safety
• Explain risks and benefits, offer alternatives like increased rounding and a low bed, and document the refusal
• Apply bilateral wrist restraints instead
• Discharge planning immediately due to noncompliance

Correct Answer: Explain risks and benefits, offer alternatives like increased rounding and a low bed, and document the refusal

Q30. Which task can be delegated to an unlicensed assistive personnel (UAP) to help prevent falls?

• Educate the patient about orthostatic hypotension precautions
• Assess gait and balance for assistive device needs
• Apply non-skid footwear and ensure the call light and personal items are within reach
• Adjust antihypertensive medications to reduce dizziness

Correct Answer: Apply non-skid footwear and ensure the call light and personal items are within reach

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