6/14/26, 1:14 NCLEX-RN flashcard sets |
PM Quizlet
NCLEX-RN Test Bank 2026-2027 | 1721 Verified Q&A
with Rationales | Fundamentals, Pharmacology, Med-
Surg, Maternity, Pediatrics, Mental Health | NCSBN
Exam Prep.
Contributing factors Fall
Older age
Impaired
mobility
Cognitive and/or Sensory
impairment Bowel and bladder
dysfuntion
Side effects of
medications History of
falls
Nursing interventions Falls
Complete a fall risk assessment
Communicate identified risks with the health care team
Assign clients at risk falls to a room close to nurses' stations and assess
frequently Provide clients with nonskid footwear
Keep the floor free of clutter and maintain an unobstructed path to
the bathroom Orient the client setting (grab bars, call light), including
how to use and locate all necessary items
Maintain bed in low position
Instruct the client who is unsteady to use the call light for assistance before
ambulating Answer call lights promptly to prevent clients who are at risk from
trying to ambulate independently
Provide adequate lighting (nightlight for necessary trips to the
bathroom) Determine the client's ability to use assistive devices
(walkers, canes, etc.). Keep all items within reach
Use chair or bed sensors for client who are at risk
Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during
transfers or stops
Report and document all incidents per the facility policy
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,6/14/26, 1:14 NCLEX-RN flashcard sets |
PM Quizlet
Nursing intervention Restraints
Implement nonpharmacologic measures such as distraction, frequent
observation, or diversion activities
Prior to application, review manufacturer's instructions for correct
application Notify the provider immediately when restraints are
implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status
every 2 hr
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Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily
removed) Reassess the need for continue use
Document
Document Restraints
Behaviors making restraint necessary
Alternatives attempted and the client's
response Type and location of restraint
and time applied Frequency and type of
assessment
Restraints should NEVER
Interfere with treatment
Be used because of short-staffing or staff
convenience Not written as PRN orders
Nursing intervention Seizure precaution
Assess seizure history, noting frequency, presence of auras, and sequence of
events Identify precipitating factors that may exacerbate or lead to seizure
Review medication history.
If routine lab work is required (Dilantin), when was last level drawn
Place rescue equipment at the bedside, including oxygen, oral airway, and
suction equipment
Establish IV or saline lock access for high risk clients
Inspects the client's environment for items that may cause injury in the event
of a seizure. Remove any unnecessary items from the immediate environment
At the onset seizure, position the client for safety, and remain with client
If sitting or standing, ease client to floor. Protect the client's head. If client is
in bed, raise the side rails and pad for safety
Roll the client to the side with the head flexed slightly
forward Do not put anything in the client's mouth
Loosen restrictive clothing
Accurately document the event, including timing precipitating behaviors or
events, and a description of the event (movements, loss of consciousness,
loss of continence, injuries, mention of aura, postictal state).
Report seizure to the provider
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, 6/14/26, 1:14 NCLEX-RN flashcard sets |
PM Quizlet
Fire response
https://quizlet.com/search?query=NCLEX 4/322
%252DRN&type=sets&page=4
PM Quizlet
NCLEX-RN Test Bank 2026-2027 | 1721 Verified Q&A
with Rationales | Fundamentals, Pharmacology, Med-
Surg, Maternity, Pediatrics, Mental Health | NCSBN
Exam Prep.
Contributing factors Fall
Older age
Impaired
mobility
Cognitive and/or Sensory
impairment Bowel and bladder
dysfuntion
Side effects of
medications History of
falls
Nursing interventions Falls
Complete a fall risk assessment
Communicate identified risks with the health care team
Assign clients at risk falls to a room close to nurses' stations and assess
frequently Provide clients with nonskid footwear
Keep the floor free of clutter and maintain an unobstructed path to
the bathroom Orient the client setting (grab bars, call light), including
how to use and locate all necessary items
Maintain bed in low position
Instruct the client who is unsteady to use the call light for assistance before
ambulating Answer call lights promptly to prevent clients who are at risk from
trying to ambulate independently
Provide adequate lighting (nightlight for necessary trips to the
bathroom) Determine the client's ability to use assistive devices
(walkers, canes, etc.). Keep all items within reach
Use chair or bed sensors for client who are at risk
Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during
transfers or stops
Report and document all incidents per the facility policy
https://quizlet.com/search?query=NCLEX 1/322
%252DRN&type=sets&page=4
,6/14/26, 1:14 NCLEX-RN flashcard sets |
PM Quizlet
Nursing intervention Restraints
Implement nonpharmacologic measures such as distraction, frequent
observation, or diversion activities
Prior to application, review manufacturer's instructions for correct
application Notify the provider immediately when restraints are
implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status
every 2 hr
https://quizlet.com/search?query=NCLEX 2/322
%252DRN&type=sets&page=4
,6/14/26, 1:14 NCLEX-RN flashcard sets |
PM Quizlet
Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily
removed) Reassess the need for continue use
Document
Document Restraints
Behaviors making restraint necessary
Alternatives attempted and the client's
response Type and location of restraint
and time applied Frequency and type of
assessment
Restraints should NEVER
Interfere with treatment
Be used because of short-staffing or staff
convenience Not written as PRN orders
Nursing intervention Seizure precaution
Assess seizure history, noting frequency, presence of auras, and sequence of
events Identify precipitating factors that may exacerbate or lead to seizure
Review medication history.
If routine lab work is required (Dilantin), when was last level drawn
Place rescue equipment at the bedside, including oxygen, oral airway, and
suction equipment
Establish IV or saline lock access for high risk clients
Inspects the client's environment for items that may cause injury in the event
of a seizure. Remove any unnecessary items from the immediate environment
At the onset seizure, position the client for safety, and remain with client
If sitting or standing, ease client to floor. Protect the client's head. If client is
in bed, raise the side rails and pad for safety
Roll the client to the side with the head flexed slightly
forward Do not put anything in the client's mouth
Loosen restrictive clothing
Accurately document the event, including timing precipitating behaviors or
events, and a description of the event (movements, loss of consciousness,
loss of continence, injuries, mention of aura, postictal state).
Report seizure to the provider
https://quizlet.com/search?query=NCLEX 3/322
%252DRN&type=sets&page=4
, 6/14/26, 1:14 NCLEX-RN flashcard sets |
PM Quizlet
Fire response
https://quizlet.com/search?query=NCLEX 4/322
%252DRN&type=sets&page=4
