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NCLEX · Safety and Infection Control

A nurse is implementing fall precautions for an older adult client at high risk for falls. Which intervention is appropriate?

Reviewed by Jordan Morley, Editorial Lead at 247SimpleTests. Written by the 247SimpleTests Editorial Team from the official source material cited on every question.

Correct answer

Keep the bed in the lowest position, ensure the call light is within reach, and provide nonskid footwear

  1. A Keep the room dark to encourage rest
  2. B Leave the client unattended in the bathroom
  3. C Keep the bed in the lowest position, ensure the call light is within reach, and provide nonskid footwear
  4. D Keep all four side rails up at all times

Why this is the answer

FALL PRECAUTIONS for a high-risk client include: keeping the BED in the LOWEST position with wheels locked; CALL LIGHT and personal items within REACH; NONSKID footwear; adequate LIGHTING (including night lights); clear pathways (remove clutter); assist with ambulation/toileting; frequent rounding; possibly a bed/chair alarm. NCLEX safe care/safety.

Note: keeping ALL FOUR side rails up is considered a RESTRAINT and can increase injury (clients climb over them) — generally avoided. Never leave a high-fall-risk client unattended in the bathroom. A dark room INCREASES fall risk. Falls are a major safety/quality concern; knowing appropriate fall precautions is heavily tested.

Source: NCLEX Safe Care — Fall Precautions

Practice more questions

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About this topic: Safety and Infection Control

Safety and infection control questions cover Standard and transmission-based precautions, isolation set-up, sterile technique, error prevention, restraints, and emergency and disaster response. This is one of 24 RN: Safe and Effective Care Environment questions on safety and infection control, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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