Fall Prevention and Restraint Safety: What the NCLEX Tests

Fundamentals · Safety & Infection Control·Updated 2026-10-28

What it is

A fall results from intrinsic factors (age, orthostatic hypotension, impaired gait or balance, confusion, urgency and nocturia) combined with extrinsic factors (sedatives, opioids, diuretics, antihypertensives, clutter, poor lighting). Restraints do not prevent falls: they increase agitation, delirium, pressure injury, aspiration and strangulation. Nursing care therefore removes the cause of the risk first and uses a restraint only as a last resort, with an order, for the shortest time.

What the NCLEX focuses on

Fall risk is screened on admission, after any change in condition and after every fall.
High-risk findings: a previous fall, sedative or opioid at bedtime, diuretics, orthostatic hypotension, a positive Romberg test, confusion and nighttime voiding.
Universal precautions: bed in the lowest locked position, call light and belongings within reach, nonskid footwear, night light and a clear path to the bathroom.
All four side rails raised is a restraint and raises injury risk from climbing over them.
Before a restraint, look for the cause of agitation: pain, a full bladder, hypoxemia, infection or delirium.
A restraint needs a provider order; it is never prescribed PRN or as a standing order. A drug used only to control behavior is a chemical restraint.
After a fall, assess for injury and neurologic change before moving the client; a client taking an anticoagulant needs close neurologic monitoring for intracranial bleeding.

Priority nursing actions

Screen fall risk and apply universal fall precautions.
Address individual causes: scheduled toileting, orthostatic vital signs, review of sedatives and diuretics with the provider.
For agitation, try alternatives: reorientation, family presence or a sitter, bed or chair alarm, covering lines and dressings.
If a restraint is still needed, obtain the order and apply the least restrictive device.
Monitor circulation, skin and behavior, release regularly, and remove the restraint as soon as criteria are met.

Numbers to know

Item	Standard	Why it matters
Orthostatic hypotension	Systolic drop of 20 mm Hg or diastolic drop of 10 mm Hg within 3 minutes of standing	Dizziness on rising causes falls
Restraint fit	Two fingers between the restraint and the skin	Prevents impaired circulation and skin injury
Restraint attachment	Bed frame, quick-release knot, never the side rail	Side rails pull the limb when lowered or raised
Restraint checks	Circulation, skin and safety every 15 to 30 minutes per agency policy	Detects injury early
Restraint release	At least every 2 hours for range of motion, toileting, fluids and skin care	Prevents contractures and pressure injury
Violent-behavior restraint order	Adults 4 hours; ages 9 to 17, 2 hours; under 9, 1 hour	Federal limit before renewal

Common exam traps

Choosing to raise all four side rails for a confused client: wrong because it is a restraint and the client climbs over them.
Choosing to apply wrist restraints before assessing pain, bladder and oxygenation: wrong because an untreated cause drives the behavior.
Choosing to help the client back to bed first after a fall: wrong because injury and neurologic status are assessed before moving.
Choosing to tie the restraint to the side rail: wrong because moving the rail injures the client.
Choosing a PRN restraint order or a PRN antipsychotic for a loud but safe client: wrong because both are prohibited restraint practices.

What to teach

Sit on the edge of the bed for a moment before standing, and call for help to get up while in the hospital.
At home, remove throw rugs and cords, add night lights, grab bars and nonslip mats, and wear well-fitting nonskid shoes.
Report dizziness or new drowsiness after a medication change.
Family: a restraint is temporary, is checked often and is removed as soon as the client is safe.

Client handout: Preventing Falls at Home (nurse guide and printable patient handout).

Try 2 NCLEX-style questions on this topic

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Question 1 · QID 221BF0B1

A nurse applies bilateral soft wrist restraints to an adult client who has a current, appropriately written order. For each action, indicate whether it is correct or requires correction.

	Correct	Requires correction
Plans one circulation and skin check at the end of the shift
Ties the straps to the movable bed frame with a quick-release knot
Leaves two fingers of slack between the restraint and the wrist
Releases the restraints every 2 hours for range of motion
Secures the straps to the side rail so the client can be turned

Question 2 · QID B8A58175

An 84-year-old client is admitted at 2200 for observation after a syncopal episode. The client is oriented to person only, takes furosemide and zolpidem at home, and reports getting up three times most nights to void. Which action should the nurse take first to reduce this client's risk of falling?

Select the best answer.

A. Activate a bed-exit alarm and schedule the next safety round in 2 hours while relying on the alarm to alert staff if the client attempts to get up
B. Lower the bed fully and place the call light within easy reach
C. Raise all four side rails and position the bedside table against the bed so the confused client is less likely to attempt an unassisted nighttime exit
D. Ask a family member to stay continuously at the bedside overnight and rely on the family member to assist whenever the client attempts to get up

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More tips on Fundamentals

Isolation Precautions and PPE: What the NCLEX TestsMatch each infection to airborne, droplet or contact precautions, put PPE on and take it off in the right order, and avoid the classic transport traps.Lab Values to Know Cold for the NCLEXKnow the core normal ranges, which abnormal results are dangerous now, and the first nursing action for each critical value.Enteral Feeding and Aspiration Prevention: What the NCLEX TestsVerify tube placement, keep the head of the bed up, recognize aspiration and intolerance, and give medications through a feeding tube safely.

Sources

Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. Elsevier; 2021; Chapter: Patient Safety and Quality.
Centers for Medicare and Medicaid Services. Conditions of Participation for Hospitals: Patient's Rights, Restraint or Seclusion. 42 CFR 482.13(e).

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