Falls, restraints and client identification

51 NCLEX-RN practice questions on Falls, restraints and client identification, part of Safety and Infection Prevention and Control. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard · Select all that apply
An 84-year-old client with new delirium has tried to get out of bed alone twice tonight and takes furosemide at 1800. Which interventions should the nurse include in the plan?
1. AUse a bed exit alarm with the bed in its lowest position
2. BRaise all four side rails for the night
3. CPlace a floor mat beside the bed
4. DOffer toileting every 2 hours and before sleep
5. EApply a vest restraint until morning
6. FAsk the provider about moving the furosemide dose to the morning
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Answer: A, C, D, F
Generate solutions: the plan targets the causes (night diuresis, unmet toileting needs) and lowers injury (alarm, low bed, mat). Four raised rails and vest restraints increase serious injury in a confused client.
- B: Confused clients climb over full rails and fall from a greater height.
- E: Restraints do not prevent falls and add injury risk; alternatives come first.
Question 2 · Hard · Matrix
An unconscious adult with no identification arrives in the emergency department after a road crash. For each practice, indicate whether it is acceptable or not acceptable.
For each row, choose: Acceptable / Not acceptable
1. Use 'Trauma bay 3' on the specimen labels
2. Label blood for type and crossmatch with the temporary name and number at the bedside
3. Apply a band with a temporary name and a unique medical record number
4. Change the band to the real name once confirmed, keeping the record linked
5. Hold all specimens unlabeled until the family arrives
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Answer:
- Use 'Trauma bay 3' on the specimen labels: Not acceptable
- Label blood for type and crossmatch with the temporary name and number at the bedside: Acceptable
- Apply a band with a temporary name and a unique medical record number: Acceptable
- Change the band to the real name once confirmed, keeping the record linked: Acceptable
- Hold all specimens unlabeled until the family arrives: Not acceptable
Take action: an unidentified client gets a temporary name and a unique number at once, so tests and blood can proceed with two identifiers. Locations are never identifiers. When identity is confirmed, the record is linked to keep every result traceable.
- Use 'Trauma bay 3' on the specimen labels: A location is not an identifier, and the client will move.
- Label blood for type and crossmatch with the temporary name and number at the bedside: The temporary identifiers are used consistently for specimens and blood.
- Apply a band with a temporary name and a unique medical record number: A temporary alias plus a unique number gives two identifiers until the real name is known.
- Change the band to the real name once confirmed, keeping the record linked: Records are merged or linked so that results and blood stay traceable.
- Hold all specimens unlabeled until the family arrives: Unlabeled specimens are rejected and delay urgent care.
Question 3 · Medium · Select all that apply
A client in soft wrist restraints for a medical (nonviolent) reason has a valid order. Which items must the nurse document?
1. AThe client behavior that made the restraint necessary
2. BThe client's response and readiness for release
3. CThat an incident report was filed about the restraint
4. DCirculation, skin and comfort checks at set intervals
5. EA standing order to restart restraints as needed
6. FLess restrictive measures tried before the restraint
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Answer: A, B, D, F
Take action: restraint documentation shows why it was needed, what was tried first, how the client was monitored and when release criteria were met. Restraint orders are never written as needed. Incident reports stay out of the chart.
- C: Incident reports are not mentioned in the client's record.
- E: PRN or standing restraint orders are not permitted.
Question 4 · Medium · Select all that apply
The nurse applies a soft wrist restraint to an adult in bed. Which actions are correct?
1. APad bony areas under the cuff
2. BSecure the strap to the bed frame
3. CTie it with a quick-release knot
4. DTie the strap to the side rail
5. EUse a square knot so it cannot slip
6. FRelease and reassess the limb at set intervals
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Answer: A, B, C, F
Take action: quick-release knots, attachment to the frame, padding and timed release keep a restraint safe. Side-rail ties and fixed knots cause injury and delay emergency release.
- D: Lowering the rail can pull on the limb and injure it.
- E: A square knot cannot be undone quickly in an emergency.
Question 5 · Hard · Select all that apply
A client is scheduled for an MRI of the brain. Which findings from the safety screen should the nurse report to the MRI team before the scan?
1. AA nitroglycerin patch with a foil backing
2. BA shellfish allergy with past hives
3. CAn insulin pump worn on the abdomen
4. DA cardiac pacemaker placed 5 years ago
5. ETooth-colored composite dental fillings
6. FMetal fragments in the eye from welding work
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Answer: A, C, D, F
Recognize cues: implanted devices, metal fragments and metal-backed patches or pumps can move, heat or fail in the magnetic field. Each must be reported before the client enters the scanner. A shellfish allergy and composite fillings do not affect MRI safety.
- B: MRI contrast is gadolinium, not iodine; shellfish allergy is not an MRI risk.
- E: Composite fillings contain no ferromagnetic metal.
Question 6 · Medium · Matrix
A client with poorly controlled epilepsy is admitted. For each planned action, indicate whether it is indicated or contraindicated.
For each row, choose: Indicated / Contraindicated
1. Take temperature with a glass oral thermometer
2. Supervise the client while showering
3. Keep a padded tongue blade at the bedside
4. Keep the bed low with padded upper side rails raised
5. Shave with an electric razor rather than a blade
Answer and explanation in LearnFree account
Question 7 · Medium · Matrix
The nurse watches assistive personnel help a client with right-sided weakness move from bed to chair. For each action, indicate whether it is safe or unsafe.
For each row, choose: Safe / Unsafe
1. Lifts by bending at the waist with straight knees
2. Has the client sit on the edge of the bed first
3. Applies a gait belt snugly around the client's waist
4. Locks the wheelchair brakes before the transfer
5. Places the chair on the client's right side
Answer and explanation in LearnFree account
Question 8 · Hard · Select all that apply
The barcode scanner cannot read a client's wristband before a scheduled IV antibiotic. Which actions should the nurse take?
1. AUse the bed number to confirm the right client
2. BScan a spare label taped to the bedside table
3. CHave a new wristband printed and placed before the dose
4. DConfirm the name and birth date with the client
5. EReport the scanning failure as a safety event
6. FOverride the alert because the client is known to the nurse
Answer and explanation in LearnFree account
Question 9 · Medium · Select all that apply
During the admission history before surgery, which client statements indicate the need for latex precautions?
1. AMy hands itch after I wear rubber cleaning gloves.
2. BMy lips swell when I blow up party balloons.
3. CI had hives after eating eggs as a child.
4. DI get an itchy mouth when I eat banana or kiwi.
5. EI was born with spina bifida and had many surgeries.
6. FI break out in a rash when I take penicillin.
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Question 10 · Medium · Select all that apply
Which nurse actions meet the national patient safety goal for identifying clients correctly?
1. AMatching the wristband to the medication record
2. BAsking the client to state the full name and birth date
3. CChecking the name card on the headboard
4. DUsing the room number as the second identifier
5. ELabeling a urine cup back at the nurses' station
6. FLabeling blood tubes at the bedside in the client's presence
Answer and explanation in LearnFree account
Question 11 · Medium · Select all that apply
A confused client keeps pulling at a peripheral IV line in the forearm. Which measures should the nurse try before considering restraints?
1. AAsk a family member to sit with the client
2. BCover the IV site with a stretch sleeve
3. CReorient the client and explain the line often
4. DGive PRN haloperidol so the client stays calm
5. EOffer toileting, fluids and comfort on a schedule
6. FMove the client to a room near the nurses' station
Answer and explanation in LearnFree account
Question 12 · Medium · Select all that apply
An older adult was found on the floor and has been assessed and returned to bed with no obvious injury. Which follow-up actions are appropriate?
1. ATell the client's family about the fall
2. BRepeat neurological and vital sign checks as per policy
3. CReassess fall risk and update the care plan
4. DNotify the health care provider of the fall
5. EComplete a safety event report
6. FWrite 'incident report filed' in the nurses' notes
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Question 13 · Medium · Matrix
An adult on a psychiatric unit is placed in seclusion for violent behavior. For each nursing action, indicate whether it is appropriate or inappropriate.
For each row, choose: Appropriate / Inappropriate
1. Monitor the client continuously while in seclusion
2. Offer fluids, food and toileting at regular times
3. Remove belts, shoelaces and sharp items first
4. Tell the client seclusion is the result of rude talk
5. Continue seclusion after the client is calm
Answer and explanation in LearnFree account
Question 14 · Medium · Select all that apply
A client on a medical unit begins a generalized tonic-clonic seizure while sitting in a chair. Which actions should the nurse take during the seizure?
1. APlace a padded tongue blade between the teeth
2. BEase the client to the floor and protect the head
3. CGive sips of water as the jerking slows
4. DHold the arms and legs to stop the jerking
5. ENote the start time and the movements seen
Answer and explanation in LearnFree account
Question 15 · Easy · Matrix
The nurse checks electrical equipment in a client's room. For each item, indicate whether it is safe to use or should not be used.
For each row, choose: Safe to use / Do not use
1. Monitor with a current safety inspection label
2. Client's own hair dryer not checked by the facility
3. Infusion pump with a cracked outer casing
4. Power strip brought from home to charge a phone
5. Bed with a three-prong plug in a wall outlet
Answer and explanation in LearnFree account
Question 16 · Hard · Matrix
A nurse precepts a new graduate. For each identification practice, indicate whether it meets the standard.
For each row, choose: Meets the standard / Does not meet the standard
1. Comparing the medical record number on the band with the order
2. Accepting the roommate's word for a client who cannot speak
3. Asking 'Are you Mrs. Ortega?' before a dose
4. Confirming a long-term care resident by a current photo and full name on the record
5. Checking name and birth date on the wristband against the blood bag tag with a second nurse at the bedside
Answer and explanation in LearnFree account
Question 17 · Hard · Select all that apply
An adult has been in four-point restraints for violent behavior for 3 hours. The nurse reviews the client's care. Which findings require the nurse to act?
1. AThe client has been calm and following directions for 30 minutes
2. BThe current 4-hour order was written 3 hours ago
3. CNo fluids or toileting offered since placement
4. DThe ankle straps are tied to the side rails
5. EThe face-to-face evaluation was done in 40 minutes
6. FThe order reads 'restraints PRN for agitation'
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Question 18 · Hard · Matrix
For each measure used on a medical unit, indicate whether it counts as a restraint.
For each row, choose: Restraint / Not a restraint
1. A sedative given only to stop a client from wandering
2. An arm board taped to stabilize an IV at the elbow
3. Two upper rails raised for a client who can exit at the foot
4. Mitts tied to the bed so a client cannot reach a feeding tube
5. A locked lap tray on a chair that the client cannot remove
Answer and explanation in LearnFree account
Question 19 · Hard · Select all that apply
A client on seizure precautions has a tonic-clonic seizure. Which findings require immediate action by the nurse?
1. AUrinary incontinence during the seizure
2. BSpO2 of 84% after the jerking stops
3. CA second seizure before regaining awareness
4. DContinuous convulsions lasting 6 minutes
5. EDrowsiness for 15 minutes after the seizure
Answer and explanation in LearnFree account
Question 20 · Medium · Matrix
The nurse reviews the medication list of an 80-year-old client at risk for falls. For each drug, indicate whether it raises fall risk.
For each row, choose: Raises fall risk / Does not raise fall risk
1. Docusate sodium daily
2. Topical diclofenac gel to the knee
3. Oxycodone for back pain
4. Furosemide twice daily
5. Zolpidem at bedtime
Answer and explanation in LearnFree account
Question 21 · Easy · Select all that apply
The nurse completes a fall-risk screen on a newly admitted older adult. Which client factors raise the risk of a fall?
1. AWalking with a cane since a knee injury
2. BWearing prescription reading glasses
3. CTaking a loop diuretic each evening
4. DA fall at home within the past 3 months
5. EA normal-range blood glucose of 96 mg/dL
6. FUrinary urgency several times a night
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Question 22 · Medium
A nurse raises all four side rails on the bed of an oriented adult who did not ask for them and cannot lower them. Under federal hospital rules, this practice is regarded as:
1. AAcceptable if charted each shift
2. BA physical restraint
3. CA routine fall precaution
4. DA required measure after age 65
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Question 23 · Medium
A client in bed begins a generalized tonic-clonic seizure. The nurse's first action is to:
1. AHold the arms and legs still
2. BGive a sip of water to protect the throat
3. CTurn the client onto one side
4. DInsert an oral airway between the teeth
Answer and explanation in LearnFree account
Question 24 · Hard
At 0300 four alerts sound on a medical unit. Which client should the nurse go to first?
1. AA 79-year-old whose bed alarm is ringing 30 minutes after IV hydromorphone
2. BA client with a latex allergy asking for latex-free gloves for home
3. CA client on seizure precautions who is asking for an extra blanket
4. DA client in wrist restraints whose 2-hour release check is due in 15 minutes
Answer and explanation in LearnFree account
Question 25 · Easy
Before giving a scheduled medication, the nurse must identify the client using two identifiers. Which pair meets this standard?
1. AFull name and date of birth
2. BRoom number and bed number
3. CDate of birth and diagnosis
4. DFull name and room number
Answer and explanation in LearnFree account

26 more Falls, restraints and client identification questions

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Falls, restraints and client identification

An 84-year-old client with new delirium has tried to get out of bed alone twice tonight and takes furosemide at 1800. Which interventions should the nurse include in the plan?

An unconscious adult with no identification arrives in the emergency department after a road crash. For each practice, indicate whether it is acceptable or not acceptable.

A client in soft wrist restraints for a medical (nonviolent) reason has a valid order. Which items must the nurse document?

The nurse applies a soft wrist restraint to an adult in bed. Which actions are correct?

A client is scheduled for an MRI of the brain. Which findings from the safety screen should the nurse report to the MRI team before the scan?

A client with poorly controlled epilepsy is admitted. For each planned action, indicate whether it is indicated or contraindicated.

The nurse watches assistive personnel help a client with right-sided weakness move from bed to chair. For each action, indicate whether it is safe or unsafe.

The barcode scanner cannot read a client's wristband before a scheduled IV antibiotic. Which actions should the nurse take?

During the admission history before surgery, which client statements indicate the need for latex precautions?

Which nurse actions meet the national patient safety goal for identifying clients correctly?

A confused client keeps pulling at a peripheral IV line in the forearm. Which measures should the nurse try before considering restraints?

An older adult was found on the floor and has been assessed and returned to bed with no obvious injury. Which follow-up actions are appropriate?

An adult on a psychiatric unit is placed in seclusion for violent behavior. For each nursing action, indicate whether it is appropriate or inappropriate.

A client on a medical unit begins a generalized tonic-clonic seizure while sitting in a chair. Which actions should the nurse take during the seizure?

The nurse checks electrical equipment in a client's room. For each item, indicate whether it is safe to use or should not be used.

A nurse precepts a new graduate. For each identification practice, indicate whether it meets the standard.

An adult has been in four-point restraints for violent behavior for 3 hours. The nurse reviews the client's care. Which findings require the nurse to act?

For each measure used on a medical unit, indicate whether it counts as a restraint.

A client on seizure precautions has a tonic-clonic seizure. Which findings require immediate action by the nurse?

The nurse reviews the medication list of an 80-year-old client at risk for falls. For each drug, indicate whether it raises fall risk.

The nurse completes a fall-risk screen on a newly admitted older adult. Which client factors raise the risk of a fall?

A nurse raises all four side rails on the bed of an oriented adult who did not ask for them and cannot lower them. Under federal hospital rules, this practice is regarded as:

A client in bed begins a generalized tonic-clonic seizure. The nurse's first action is to:

At 0300 four alerts sound on a medical unit. Which client should the nurse go to first?

Before giving a scheduled medication, the nurse must identify the client using two identifiers. Which pair meets this standard?