NURS 101L | Patient Safety & Fall Prevention Skills | 2026 Update
WCU
1. A nurse is performing a fall risk assessment using the Morse Fall Scale. Which
factor contributes the most points to the patient’s total score?
A. Age over 65 years
B. History of falling within the last 3 months
C. Secondary diagnosis
D. Presence of an IV saline lock
Answer: B
Rationale: In the Morse Fall Scale, a history of falling (immediate or within 3 months) is a
significant predictor and adds 25 points to the score, which is the highest weighted single
item.
2. When assisting a patient with left-sided weakness to ambulate with a gait
belt, where should the nurse stand?
A. On the patient’s left side, slightly behind
B. In front of the patient, walking backward
C. On the patient’s right side, slightly behind
D. Directly behind the patient
Answer: A
Rationale: The nurse should stand on the patient’s weaker (affected) side and slightly
behind to provide the best support and stability during ambulation.
,3. Which of the following interventions is considered a restraint alternative?
A. Tying a sheet across the patient’s lap
B. Raising all four side rails
C. Using a bed alarm system
D. Administering PRN haloperidol for agitation
Answer: C
Rationale: Bed alarms are non-invasive monitoring devices intended to alert staff when a
patient attempts to exit the bed, serving as a primary alternative to physical restraints.
4. A nurse finds a patient on the floor after a fall. What is the immediate priority
action?
A. Assess the patient’s airway, breathing, and circulation
B. Notify the provider
C. Complete an incident report
D. Assist the patient back into bed
Answer: A
Rationale: Patient safety and physical assessment come first. The nurse must check for
injury and vital signs before attempting to move the patient or performing administrative
tasks.
5. An adult patient is placed in physical restraints for violent behavior.
According to Joint Commission standards, how often must the provider renew
the order?
A. Every 24 hours
B. Every 8 hours
C. Every 4 hours
D. Every 2 hours
Answer: C
, Rationale: For violent or self-destructive behavior in adults (18+), a restraint order must
be renewed every 4 hours.
6. When applying a wrist restraint, the nurse should ensure which of the
following?
A. The restraint is tied to the side rail for easy access
B. Two fingers can fit between the restraint and the wrist
C. The patient’s hand is kept in a fist
D. A square knot is used for security
Answer: B
Rationale: Ensuring two fingers fit under the restraint prevents constriction of circulation
and nerve damage. Restraints should always be tied to the bed frame, not the side rail.
7. Which medication class is most likely to increase a patient’s risk of orthostatic
hypotension and subsequent falls?
A. Antibiotics
B. Stool softeners
C. Antihypertensives
D. Proton pump inhibitors
Answer: C
Rationale: Antihypertensives, such as beta-blockers or diuretics, can cause a sudden drop
in blood pressure when the patient stands up, leading to dizziness and falls.
8. What does a yellow wristband signify in most hospital settings?
A. Fall risk
B. Do Not Resuscitate (DNR)
C. Allergy alert
D. Latex allergy
Answer: A
WCU
1. A nurse is performing a fall risk assessment using the Morse Fall Scale. Which
factor contributes the most points to the patient’s total score?
A. Age over 65 years
B. History of falling within the last 3 months
C. Secondary diagnosis
D. Presence of an IV saline lock
Answer: B
Rationale: In the Morse Fall Scale, a history of falling (immediate or within 3 months) is a
significant predictor and adds 25 points to the score, which is the highest weighted single
item.
2. When assisting a patient with left-sided weakness to ambulate with a gait
belt, where should the nurse stand?
A. On the patient’s left side, slightly behind
B. In front of the patient, walking backward
C. On the patient’s right side, slightly behind
D. Directly behind the patient
Answer: A
Rationale: The nurse should stand on the patient’s weaker (affected) side and slightly
behind to provide the best support and stability during ambulation.
,3. Which of the following interventions is considered a restraint alternative?
A. Tying a sheet across the patient’s lap
B. Raising all four side rails
C. Using a bed alarm system
D. Administering PRN haloperidol for agitation
Answer: C
Rationale: Bed alarms are non-invasive monitoring devices intended to alert staff when a
patient attempts to exit the bed, serving as a primary alternative to physical restraints.
4. A nurse finds a patient on the floor after a fall. What is the immediate priority
action?
A. Assess the patient’s airway, breathing, and circulation
B. Notify the provider
C. Complete an incident report
D. Assist the patient back into bed
Answer: A
Rationale: Patient safety and physical assessment come first. The nurse must check for
injury and vital signs before attempting to move the patient or performing administrative
tasks.
5. An adult patient is placed in physical restraints for violent behavior.
According to Joint Commission standards, how often must the provider renew
the order?
A. Every 24 hours
B. Every 8 hours
C. Every 4 hours
D. Every 2 hours
Answer: C
, Rationale: For violent or self-destructive behavior in adults (18+), a restraint order must
be renewed every 4 hours.
6. When applying a wrist restraint, the nurse should ensure which of the
following?
A. The restraint is tied to the side rail for easy access
B. Two fingers can fit between the restraint and the wrist
C. The patient’s hand is kept in a fist
D. A square knot is used for security
Answer: B
Rationale: Ensuring two fingers fit under the restraint prevents constriction of circulation
and nerve damage. Restraints should always be tied to the bed frame, not the side rail.
7. Which medication class is most likely to increase a patient’s risk of orthostatic
hypotension and subsequent falls?
A. Antibiotics
B. Stool softeners
C. Antihypertensives
D. Proton pump inhibitors
Answer: C
Rationale: Antihypertensives, such as beta-blockers or diuretics, can cause a sudden drop
in blood pressure when the patient stands up, leading to dizziness and falls.
8. What does a yellow wristband signify in most hospital settings?
A. Fall risk
B. Do Not Resuscitate (DNR)
C. Allergy alert
D. Latex allergy
Answer: A
