NURS 121L-B: Patient Safety, Fall Prevention & Risk Reduction (2026
Update) WCU
1. A nurse is conducting a Morse Fall Scale assessment for a 78-year-old client
with a history of hypertension. The client has fallen once in the last 3 months,
uses a walker, and has an IV access point. Which score accurately reflects the
client’s fall risk category?
A. Low Risk (0-24)
B. Moderate Risk (25-44)
C. High Risk (45 or higher)
D. Very High Risk (75 or higher)
Answer: C
Rationale: Using the Morse Fall Scale: History of falling (25), ambulatory aid like a walker
(15), and IV access (20) totals at least 60, placing the client in the high-risk category (45 or
higher).
2. According to the 2026 National Patient Safety Goals (NPSG), which action is
the most critical first step when responding to a clinical alarm?
A. Assessing the patient’s physiological status immediately.
B. Verifying the alarm settings match the physician’s orders.
C. Silencing the alarm to prevent alarm fatigue among staff.
D. Checking the equipment for mechanical failure or disconnection.
Answer: A
Rationale: The priority is always patient assessment to determine if the alarm reflects a
life-threatening change in status before troubleshooting equipment.
,3. A confused client is attempting to pull out their central venous catheter. The
nurse receives an order for soft wrist restraints. Which nursing intervention is a
legal requirement for restraint maintenance?
A. Removing the restraints every 4 hours for range of motion.
B. Documenting a neurovascular assessment every 2 hours.
C. Obtaining a new written order every 48 hours.
D. Assessing the need for restraints only during shift change.
Answer: B
Rationale: For non-behavioral restraints, neurovascular assessments and skin integrity
checks are required at least every 2 hours to prevent injury.
4. Which intrinsic risk factor most significantly increases the likelihood of a fall-
related hip fracture in an elderly post-menopausal woman?
A. Poor room illumination
B. Osteoporosis and decreased bone density
C. Use of an unsecured throw rug
D. Orthostatic hypotension
Answer: B
Rationale: While others are risk factors for falls, osteoporosis is the intrinsic factor that
specifically increases the severity of the outcome (fracture) from a fall.
5. The nurse is implementing ‘Just Culture’ principles after a medication error
occurs due to a faulty barcode scanner. What is the primary focus of this
approach?
A. Identifying and disciplining the nurse who made the error.
B. Assigning blame to the IT department for equipment failure.
C. Maintaining a zero-tolerance policy for all clinical mistakes.
D. Analyzing system failures that contributed to the error.
Answer: D
, Rationale: Just Culture focuses on identifying system-wide vulnerabilities and
distinguishing between human error, risky behavior, and reckless behavior rather than
simple punishment.
6. A client is prescribed Furosemide 40mg IV twice daily. Which safety
intervention is most appropriate to prevent falls related to this medication?
A. Restricting fluid intake to 1000mL per day.
B. Keeping all four side rails up at all times.
C. Placing the client on a scheduled toileting program.
D. Providing a bedside commode only during the night shift.
Answer: C
Rationale: Diuretics increase urgency and frequency. A scheduled toileting program
reduces the client’s need to ambulate quickly or unassisted to the bathroom.
7. A ‘Near Miss’ event occurred when a nurse caught a wrong-dose medication
before administration. What is the priority action for the nurse?
A. Complete an incident/occurrence report to facilitate system improvement.
B. Notify the physician but do not file an incident report.
C. Discard the medication and take no further action since no harm occurred.
D. Report the incident to the Board of Nursing immediately.
Answer: A
Rationale: Reporting near misses is essential in a culture of safety to identify flaws in the
medication administration process before they reach a patient.
Update) WCU
1. A nurse is conducting a Morse Fall Scale assessment for a 78-year-old client
with a history of hypertension. The client has fallen once in the last 3 months,
uses a walker, and has an IV access point. Which score accurately reflects the
client’s fall risk category?
A. Low Risk (0-24)
B. Moderate Risk (25-44)
C. High Risk (45 or higher)
D. Very High Risk (75 or higher)
Answer: C
Rationale: Using the Morse Fall Scale: History of falling (25), ambulatory aid like a walker
(15), and IV access (20) totals at least 60, placing the client in the high-risk category (45 or
higher).
2. According to the 2026 National Patient Safety Goals (NPSG), which action is
the most critical first step when responding to a clinical alarm?
A. Assessing the patient’s physiological status immediately.
B. Verifying the alarm settings match the physician’s orders.
C. Silencing the alarm to prevent alarm fatigue among staff.
D. Checking the equipment for mechanical failure or disconnection.
Answer: A
Rationale: The priority is always patient assessment to determine if the alarm reflects a
life-threatening change in status before troubleshooting equipment.
,3. A confused client is attempting to pull out their central venous catheter. The
nurse receives an order for soft wrist restraints. Which nursing intervention is a
legal requirement for restraint maintenance?
A. Removing the restraints every 4 hours for range of motion.
B. Documenting a neurovascular assessment every 2 hours.
C. Obtaining a new written order every 48 hours.
D. Assessing the need for restraints only during shift change.
Answer: B
Rationale: For non-behavioral restraints, neurovascular assessments and skin integrity
checks are required at least every 2 hours to prevent injury.
4. Which intrinsic risk factor most significantly increases the likelihood of a fall-
related hip fracture in an elderly post-menopausal woman?
A. Poor room illumination
B. Osteoporosis and decreased bone density
C. Use of an unsecured throw rug
D. Orthostatic hypotension
Answer: B
Rationale: While others are risk factors for falls, osteoporosis is the intrinsic factor that
specifically increases the severity of the outcome (fracture) from a fall.
5. The nurse is implementing ‘Just Culture’ principles after a medication error
occurs due to a faulty barcode scanner. What is the primary focus of this
approach?
A. Identifying and disciplining the nurse who made the error.
B. Assigning blame to the IT department for equipment failure.
C. Maintaining a zero-tolerance policy for all clinical mistakes.
D. Analyzing system failures that contributed to the error.
Answer: D
, Rationale: Just Culture focuses on identifying system-wide vulnerabilities and
distinguishing between human error, risky behavior, and reckless behavior rather than
simple punishment.
6. A client is prescribed Furosemide 40mg IV twice daily. Which safety
intervention is most appropriate to prevent falls related to this medication?
A. Restricting fluid intake to 1000mL per day.
B. Keeping all four side rails up at all times.
C. Placing the client on a scheduled toileting program.
D. Providing a bedside commode only during the night shift.
Answer: C
Rationale: Diuretics increase urgency and frequency. A scheduled toileting program
reduces the client’s need to ambulate quickly or unassisted to the bathroom.
7. A ‘Near Miss’ event occurred when a nurse caught a wrong-dose medication
before administration. What is the priority action for the nurse?
A. Complete an incident/occurrence report to facilitate system improvement.
B. Notify the physician but do not file an incident report.
C. Discard the medication and take no further action since no harm occurred.
D. Report the incident to the Board of Nursing immediately.
Answer: A
Rationale: Reporting near misses is essential in a culture of safety to identify flaws in the
medication administration process before they reach a patient.
