NR 224 – Fundamentals of Nursing: Safety, Fall
Prevention & Patient Environment
100 NCLEX®-Style Practice Questions with
Detailed Rationales
1. A nurse is assessing a newly admitted patient. Which intervention is the priority to promote
patient safety?
A. Provide the patient with a television remote.
B. Identify the patient using two approved identifiers.
C. Explain hospital meal schedules.
D. Organize the patient's personal belongings.
Answer: B. Identify the patient using two approved identifiers.
Rationale: Using two patient identifiers, such as name and date of birth, prevents
errors and ensures that care is provided to the correct patient.
2. A nurse is caring for a patient at high risk for falls. Which intervention is appropriate?
A. Keep the bed in the highest position.
B. Place the call light within reach.
C. Encourage the patient to ambulate independently.
D. Remove nonskid footwear.
Answer: B. Place the call light within reach.
Rationale: Keeping the call light accessible allows the patient to request assistance
and reduces unsafe attempts to get out of bed.
3. A nurse is preparing a patient's environment to reduce fall risk. Which action should the
nurse take?
,A. Keep the room dark at night.
B. Remove clutter from walkways.
C. Place personal items out of reach.
D. Keep the bed unlocked.
Answer: B. Remove clutter from walkways.
Rationale: A clear environment reduces obstacles and decreases the likelihood of
trips and falls.
4. A nurse is educating a patient about fall prevention. Which statement indicates
understanding?
A. "I should get up quickly to prevent weakness."
B. "I will call for help before getting out of bed if I feel unsteady."
C. "I do not need assistance if I use the furniture for support."
D. "I can walk barefoot if the floor is clean."
Answer: B. "I will call for help before getting out of bed if I feel unsteady."
Rationale: Calling for assistance prevents falls in patients who may have weakness,
dizziness, or impaired balance.
5. A nurse is caring for a patient who is confused and attempts to climb out of bed. Which
intervention should the nurse try first?
A. Apply restraints immediately.
B. Identify and address the cause of the behavior.
C. Raise all four side rails.
D. Sedate the patient.
Answer: B. Identify and address the cause of the behavior.
Rationale: The nurse should first assess for causes such as pain, confusion, toileting
needs, or environmental issues before using restrictive interventions.
6. A nurse is preparing to use a restraint on a patient. Which action is required before applying
the restraint?
,A. Obtain an order according to facility policy.
B. Apply it without assessment.
C. Use it as punishment.
D. Inform the family only.
Answer: A. Obtain an order according to facility policy.
Rationale: Restraints require proper authorization and should only be used when
less restrictive interventions have failed or are inappropriate.
7. A nurse is caring for a patient with a wrist restraint. Which assessment is most important?
A. Hair condition.
B. Circulation and skin integrity of the restrained extremity.
C. Food preferences.
D. Sleep pattern only.
Answer: B. Circulation and skin integrity of the restrained extremity.
Rationale: Restraints can impair circulation and cause skin injury. Frequent
assessment is required to protect patient safety.
8. A nurse is assisting a weak patient to ambulate. Which action is appropriate?
A. Allow the patient to walk without assistance.
B. Use a gait belt if indicated.
C. Encourage the patient to move quickly.
D. Stand far away from the patient.
Answer: B. Use a gait belt if indicated.
Rationale: A gait belt provides support during ambulation and reduces the risk of
falls and injury.
9. A nurse enters a patient's room and notices the floor is wet. What should the nurse do first?
A. Walk around the wet area.
B. Clean the spill or obtain assistance immediately.
, C. Leave the room without reporting it.
D. Wait for housekeeping.
Answer: B. Clean the spill or obtain assistance immediately.
Rationale: Wet floors create an immediate fall hazard. The hazard should be
corrected promptly.
10. A nurse is teaching a patient about using the call light. Which statement indicates
understanding?
A. "I should use the call light when I need assistance getting up."
B. "I should only call after I fall."
C. "I should avoid bothering staff."
D. "I can walk alone if I feel better."
Answer: A. "I should use the call light when I need assistance getting up."
Rationale: Using the call light before attempting activities that require assistance
helps prevent falls and injuries.
11. A nurse is caring for a patient who is at risk for seizures. Which safety intervention is
appropriate?
A. Keep the bed in the highest position.
B. Pad side rails according to policy.
C. Restrain the patient routinely.
D. Place objects near the patient's head.
Answer: B. Pad side rails according to policy.
Rationale: Padding side rails can reduce injury during seizure activity. Restraints are
not used routinely for seizure prevention.
12. A nurse is responding to a fire in the healthcare facility. Which action follows the RACE
protocol?
A. Rescue patients in immediate danger first.
B. Activate oxygen supplies.
Prevention & Patient Environment
100 NCLEX®-Style Practice Questions with
Detailed Rationales
1. A nurse is assessing a newly admitted patient. Which intervention is the priority to promote
patient safety?
A. Provide the patient with a television remote.
B. Identify the patient using two approved identifiers.
C. Explain hospital meal schedules.
D. Organize the patient's personal belongings.
Answer: B. Identify the patient using two approved identifiers.
Rationale: Using two patient identifiers, such as name and date of birth, prevents
errors and ensures that care is provided to the correct patient.
2. A nurse is caring for a patient at high risk for falls. Which intervention is appropriate?
A. Keep the bed in the highest position.
B. Place the call light within reach.
C. Encourage the patient to ambulate independently.
D. Remove nonskid footwear.
Answer: B. Place the call light within reach.
Rationale: Keeping the call light accessible allows the patient to request assistance
and reduces unsafe attempts to get out of bed.
3. A nurse is preparing a patient's environment to reduce fall risk. Which action should the
nurse take?
,A. Keep the room dark at night.
B. Remove clutter from walkways.
C. Place personal items out of reach.
D. Keep the bed unlocked.
Answer: B. Remove clutter from walkways.
Rationale: A clear environment reduces obstacles and decreases the likelihood of
trips and falls.
4. A nurse is educating a patient about fall prevention. Which statement indicates
understanding?
A. "I should get up quickly to prevent weakness."
B. "I will call for help before getting out of bed if I feel unsteady."
C. "I do not need assistance if I use the furniture for support."
D. "I can walk barefoot if the floor is clean."
Answer: B. "I will call for help before getting out of bed if I feel unsteady."
Rationale: Calling for assistance prevents falls in patients who may have weakness,
dizziness, or impaired balance.
5. A nurse is caring for a patient who is confused and attempts to climb out of bed. Which
intervention should the nurse try first?
A. Apply restraints immediately.
B. Identify and address the cause of the behavior.
C. Raise all four side rails.
D. Sedate the patient.
Answer: B. Identify and address the cause of the behavior.
Rationale: The nurse should first assess for causes such as pain, confusion, toileting
needs, or environmental issues before using restrictive interventions.
6. A nurse is preparing to use a restraint on a patient. Which action is required before applying
the restraint?
,A. Obtain an order according to facility policy.
B. Apply it without assessment.
C. Use it as punishment.
D. Inform the family only.
Answer: A. Obtain an order according to facility policy.
Rationale: Restraints require proper authorization and should only be used when
less restrictive interventions have failed or are inappropriate.
7. A nurse is caring for a patient with a wrist restraint. Which assessment is most important?
A. Hair condition.
B. Circulation and skin integrity of the restrained extremity.
C. Food preferences.
D. Sleep pattern only.
Answer: B. Circulation and skin integrity of the restrained extremity.
Rationale: Restraints can impair circulation and cause skin injury. Frequent
assessment is required to protect patient safety.
8. A nurse is assisting a weak patient to ambulate. Which action is appropriate?
A. Allow the patient to walk without assistance.
B. Use a gait belt if indicated.
C. Encourage the patient to move quickly.
D. Stand far away from the patient.
Answer: B. Use a gait belt if indicated.
Rationale: A gait belt provides support during ambulation and reduces the risk of
falls and injury.
9. A nurse enters a patient's room and notices the floor is wet. What should the nurse do first?
A. Walk around the wet area.
B. Clean the spill or obtain assistance immediately.
, C. Leave the room without reporting it.
D. Wait for housekeeping.
Answer: B. Clean the spill or obtain assistance immediately.
Rationale: Wet floors create an immediate fall hazard. The hazard should be
corrected promptly.
10. A nurse is teaching a patient about using the call light. Which statement indicates
understanding?
A. "I should use the call light when I need assistance getting up."
B. "I should only call after I fall."
C. "I should avoid bothering staff."
D. "I can walk alone if I feel better."
Answer: A. "I should use the call light when I need assistance getting up."
Rationale: Using the call light before attempting activities that require assistance
helps prevent falls and injuries.
11. A nurse is caring for a patient who is at risk for seizures. Which safety intervention is
appropriate?
A. Keep the bed in the highest position.
B. Pad side rails according to policy.
C. Restrain the patient routinely.
D. Place objects near the patient's head.
Answer: B. Pad side rails according to policy.
Rationale: Padding side rails can reduce injury during seizure activity. Restraints are
not used routinely for seizure prevention.
12. A nurse is responding to a fire in the healthcare facility. Which action follows the RACE
protocol?
A. Rescue patients in immediate danger first.
B. Activate oxygen supplies.
