Fall Prevention on the NCLEX
Fall risk scoring concepts, interventions that actually work, and the post-fall response.
Falls are the most common inpatient safety event. The exam tests risk recognition, then the first move after a fall.
Who is at risk
Standard tools (Morse is the common one) score the same factors: history of falling, secondary diagnoses, an ambulatory aid, IV or tethering equipment, impaired gait, and impaired mental status. Add the pharmacy layer: sedatives, opioids, antihypertensives, diuretics, hypoglycemics, and anything new. Orthostatic hypotension and toileting urgency drive a huge share of real falls. Reassess after any status change, not just on admission.
Interventions that work
Bed low and locked, call light and personal items within reach, nonslip footwear, clear path to the bathroom, adequate lighting. Purposeful hourly rounding that addresses pain, potty, position, and possessions prevents the unassisted trip that becomes a fall. Scheduled toileting for the high-risk patient beats waiting for the call light. Bed and chair alarms are an adjunct, not a plan; they tell you a fall is starting. Restraints are a last resort and increase injury risk; they are never a fall-prevention strategy of first choice. Communicate risk: wristband, door signage, handoff.
Post-fall response
Assess before you move the patient. Check responsiveness, airway, obvious injury, pain, and the ability to move extremities; suspect hip fracture (shortened, externally rotated leg) and head injury before lifting anyone off the floor. Neuro checks per policy for any possible head strike, and treat anticoagulated patients as head-injured until cleared. Notify the provider, monitor vitals, complete the incident report (the report is not part of the chart), and document objective findings in the record. A post-fall huddle asks why this fall happened and what changes now: that is the intervention for the next fall.
Frequently asked
You find a patient on the floor. First action?
Assess before moving: responsiveness, injury, pain, extremity movement. Call for help; do not lift first and examine later.
Are side rails a fall intervention?
All four rails up is a restraint and increases climbing injuries. Rails are used selectively per policy.
Fell on apixaban, no visible injury?
High concern anyway. Provider notification and neuro monitoring; anticoagulation plus any head strike can mean delayed intracranial bleeding.
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