NCLEX-RN Fall Prevention and Patient Safety — Practice Questions

PPE sequence is critical to prevent self-contamination. Donning (clean to contaminated): (1) Perform hand hygiene; (2) Gown — tied at neck and waist; (3) Mask or respirator — secure with ties or elastic; (4) Goggles or face shield — over the eyes; (5) Gloves — extending over gown cuffs. Doffing (contaminated to clean) is reversed and most critical because items are now contaminated: (1) Gloves — remove first because they are most contaminated; (2) Goggles or face shield — handle by the strap behind the head, not the front; (3) Gown — untie and roll inward, contaminated side in; (4) Mask or respirator — handle by ties or elastic, not the front; (5) Perform hand hygiene. The mask/respirator is removed last because it protected the airway throughout. Hand hygiene is performed between steps when the next item must be handled cleanly. CDC offers detailed posters for clinical reference.

Cardiac arrest requires immediate action. The current AHA Basic Life Support sequence (C-A-B): (1) Check for responsiveness; (2) Activate emergency response (call code blue, ask for AED if available); (3) Begin chest compressions immediately — 100-120 per minute, 2-2.4 inches deep on adults, allowing full recoil; (4) Open airway and provide ventilations after 30 compressions (in two-rescuer CPR, alternate). The change from A-B-C (Airway-Breathing-Circulation) to C-A-B (Compressions-Airway-Breathing) reflects evidence that early chest compressions are the single most important intervention. Don't waste time checking for breathing extensively or attempting ventilation first. The pulse check should be 5-10 seconds maximum. Continue CPR until: the client recovers, the code team takes over, you are physically exhausted, or the situation becomes unsafe. After arrest, monitor for return of spontaneous circulation (ROSC) and prepare for post-arrest care.

The RACE acronym is the standard fire response in healthcare facilities: R — Rescue any client in immediate danger; A — Activate the fire alarm (pull station) or call the emergency code; C — Contain the fire by closing doors and windows to limit oxygen and smoke spread; E — Extinguish the fire if small and contained, or Evacuate per facility policy if the fire is large or spreading. The PASS acronym applies to fire extinguisher use: Pull the pin; Aim at the base of the fire; Squeeze the handle; Sweep side to side. Healthcare evacuation is complex because many clients cannot ambulate independently — facilities have horizontal evacuation plans (move clients to a different fire zone through smoke doors) before vertical evacuation (down stairs) is attempted. Knowing the fire response is required of all healthcare staff and tested at hire and during periodic drills.

The Joint Commission's National Patient Safety Goals require using at least two patient identifiers before any procedure, medication administration, blood transfusion, specimen collection, or any other patient-specific intervention. Acceptable identifiers: full name (first and last), date of birth, medical record number, government-issued ID. Room number is NEVER acceptable — clients move rooms; mistakes happen with room assignments; and confused clients in shared rooms can lead to errors. Recognition by face is also not acceptable, even for clients you know well — fatigue, similar appearances, and changing client census all create error risk. The wristband is checked, the client is asked (when able) to state their name and date of birth, and these are matched to the medication record or procedure consent. For unconscious or non-verbal clients, identification still uses the wristband against the chart.

Competent adults have the right to refuse any medical treatment, including medications. The nurse must respect this right while ensuring informed decision-making. Steps: (1) Acknowledge the refusal calmly; (2) Explore the reason — concerns about side effects, religious beliefs, distrust, misunderstanding, feeling well; (3) Provide education about the medication's purpose, expected benefits, and risks of refusal; (4) If the client still refuses, document the refusal including the client's stated reason, the education provided, and notification of the prescriber; (5) Notify the prescriber so they can speak with the client if appropriate or adjust the treatment plan. Documentation should include the exact medication, time, client's stated reason for refusal, and actions taken. The nurse may not force medications, hide them in food without informed consent (which would be assault), or falsify documentation. Exceptions exist for involuntary psychiatric holds and emergencies, but require legal authority.

Informed consent is both an ethical and legal requirement before most medical interventions. Elements that must be communicated: nature of the proposed treatment; purpose and expected benefits; significant risks and complications; reasonable alternatives (including no treatment); consequences of refusing the treatment. The consent must be: voluntary (free from coercion); informed (the client understood); given by a competent person. The physician or provider performing the intervention is responsible for obtaining informed consent; the nurse's role is to witness the signature, verify the client appears to understand and consent voluntarily, and notify the provider if questions or concerns suggest the client does not adequately understand. The nurse does not provide informed consent for medical or surgical procedures — that is the provider's responsibility. Special situations: emergencies (consent may be implied), minors (parent/guardian consents with some exceptions), psychiatric holds.

Fall prevention is multifactorial and individualized. Standard practice: (1) Assess fall risk on admission and at regular intervals using a validated tool (Morse Fall Scale, STRATIFY, Hendrich II); (2) Identify specific risk factors — age, history of falls, gait/balance issues, vision problems, medications (especially benzodiazepines, opioids, anticholinergics), cognitive impairment, incontinence; (3) Implement individualized interventions: bed in low position; call light within reach; non-slip footwear; scheduled toileting (proactive bathroom visits before urgency); clear pathways; adequate lighting; bed alarms for high-risk clients; one-to-one observation when needed; environmental safety. Side rails are not unconditional fall prevention — full side rails can be a form of restraint and have led to entrapment injuries. Restraints are not first-line and require physician order, specific indications, and frequent reassessment. Family involvement helps. Reassess after every fall and modify the plan.

The initial nursing assessment cannot be delegated — it requires the comprehensive judgment and analysis only an RN can provide. The initial assessment establishes the baseline, identifies acute and chronic issues, develops the nursing diagnoses, and is the foundation of the care plan. This is a nursing process activity (Assessment, Diagnosis, Planning, Implementation, Evaluation — ADPIE) and the Assessment step is RN-exclusive. Subsequent data collection (such as routine vital signs on stable clients, intake/output measurements, focused observations) can be delegated to LPNs or UAPs with appropriate parameters and reporting expectations, but the comprehensive assessment, analysis of findings, and care planning are RN responsibilities. Bathing, vaccine administration (depending on state and setting), and bathroom assistance are delegable tasks within appropriate scope.

Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate action. Signs: hives, urticaria, swelling (face, lips, tongue, throat), wheezing, stridor, hypotension, shock. Priority interventions: (1) Stop the offending agent — discontinue IV infusion, remove contact; (2) Assess and maintain the airway — anaphylaxis can cause rapid airway swelling; (3) Administer epinephrine IM (epinephrine auto-injector or 1:1000 solution, 0.3-0.5 mg adult dose, IM in vastus lateralis) — epinephrine is the first-line treatment, given immediately; (4) Call rapid response or code team; (5) Position supine with legs elevated unless respiratory distress requires sitting up; (6) Administer high-flow oxygen; (7) Establish IV access for fluids and additional medications; (8) Prepare for possible intubation. Secondary medications: antihistamines (diphenhydramine), corticosteroids (methylprednisolone), bronchodilators if wheezing. Epinephrine works within minutes; a second dose may be needed in 5-15 minutes.

Nurses have an obligation to practice only within their competency. The American Nurses Association Code of Ethics and most state nurse practice acts require this. When faced with an unfamiliar assignment: communicate concerns to the charge nurse or supervisor; identify specific tasks within the nurse's competency versus those requiring additional training or supervision; request orientation, training, or supervision for unfamiliar tasks; document the conversation and the resolution. The nurse should not simply refuse and leave (this may constitute patient abandonment if clients are assigned), nor should the nurse silently accept an unsafe assignment. If the resolution is unsafe (e.g., the supervisor insists without providing support), the nurse documents the situation and escalates through the chain of command. Compromise solutions: pair the nurse with someone experienced, modify the assignment, or limit the nurse to specific tasks within competency.