NURS 104L Patient Safety and Fall Prevention Skills Comprehensive
Quiz 2026 |WCU
1. A patient scores a 55 on the Morse Fall Scale. Which risk category does this
patient fall into, and what is the required nursing action?
A. Low risk; implement standard safety precautions only.
B. Moderate risk; apply a yellow wristband and reassess in 24 hours.
C. High risk; implement a standardized high-risk fall prevention protocol.
D. Very high risk; immediate 1:1 sitter observation is mandatory.
Answer: C
Rationale: A Morse Fall Scale score of 45 or higher indicates high risk, requiring the
implementation of specific high-risk prevention strategies according to clinical standards.
2. When teaching a patient how to use a cane for stability due to left-sided
weakness, the nurse should instruct the patient to hold the cane in which hand?
A. The left hand to provide direct support to the weak side.
B. The right hand to widen the base of support and shift weight.
C. Whichever hand feels more comfortable for the patient.
D. Alternating hands to prevent muscle fatigue.
Answer: B
Rationale: A cane should be held on the stronger side (opposite the weak side) to provide
better balance and support the weight-bearing phase of the affected limb.
,3. Which assessment finding is a component of the Hendrich II Fall Risk Model
but NOT the Morse Fall Scale?
A. Confusion, disorientation, or impulsivity
B. Secondary diagnosis
C. History of falling
D. Gait or transferring ability
Answer: A
Rationale: The Hendrich II specifically assesses for confusion/impulsivity and depression,
whereas the Morse Fall Scale focuses more on history, secondary diagnosis, and
ambulatory aids.
4. Following an inpatient fall, what is the nurse’s first priority action?
A. Complete a detailed incident report for the hospital’s legal team.
B. Notify the primary care provider and the patient’s family.
C. Document the event in the patient’s medical record.
D. Assess the patient for injuries and obtain a set of vital signs.
Answer: D
Rationale: Patient safety is the priority; the nurse must first assess for injuries (like head
trauma or fractures) and stabilize the patient before reporting or documenting.
5. When transferring a patient from a bed to a wheelchair, which action by the
nurse ensures maximum safety?
A. Placing the wheelchair at a 90-degree angle to the bed.
B. Allowing the patient to wear only hospital-issued socks.
C. Lifting the patient under the axillae to provide leverage.
D. Locking the brakes on both the bed and the wheelchair.
Answer: D
Rationale: Locking the brakes prevents the equipment from moving during the transfer,
which is a leading cause of falls during patient mobilization.
, 6. The nurse is caring for an elderly patient with orthostatic hypotension. What
instruction is most important to prevent a fall?
A. ‘Dangle your legs at the bedside for 1-2 minutes before standing.’
B. ‘Drink at least 3 liters of water per day.’
C. ‘Keep your bed in the highest position to make standing easier.’
D. ‘Always walk with your head tilted slightly downward.’
Answer: A
Rationale: Dangling allows the circulatory system to adjust to postural changes,
preventing the sudden drop in blood pressure that causes dizziness and falls.
7. A healthcare provider orders a physical restraint for a combative patient.
What is a legal requirement for the nurse regarding this order?
A. The order must be renewed every 48 hours.
B. The nurse can use a PRN (as needed) order for restraints.
C. The patient’s family must sign a legal waiver before application.
D. The provider must conduct a face-to-face assessment within a specific timeframe (usually 1-4 hours).
Answer: D
Rationale: Federal and accreditation standards require a face-to-face evaluation by a
provider for the use of restraints; PRN orders for restraints are strictly prohibited.
8. Which of the following is considered a ‘restraint alternative’ that the nurse
should attempt first?
A. Applying a four-point leather restraint system.
B. Administering a dose of Lorazepam (Ativan) for agitation.
C. Using a bed alarm or chair pad sensor.
D. Raising all four side rails on the hospital bed.
Answer: C
Rationale: Restraint alternatives are non-restrictive measures, such as bed alarms, sitters,
or diversionary activities, used to maintain safety without physical or chemical restriction.
Quiz 2026 |WCU
1. A patient scores a 55 on the Morse Fall Scale. Which risk category does this
patient fall into, and what is the required nursing action?
A. Low risk; implement standard safety precautions only.
B. Moderate risk; apply a yellow wristband and reassess in 24 hours.
C. High risk; implement a standardized high-risk fall prevention protocol.
D. Very high risk; immediate 1:1 sitter observation is mandatory.
Answer: C
Rationale: A Morse Fall Scale score of 45 or higher indicates high risk, requiring the
implementation of specific high-risk prevention strategies according to clinical standards.
2. When teaching a patient how to use a cane for stability due to left-sided
weakness, the nurse should instruct the patient to hold the cane in which hand?
A. The left hand to provide direct support to the weak side.
B. The right hand to widen the base of support and shift weight.
C. Whichever hand feels more comfortable for the patient.
D. Alternating hands to prevent muscle fatigue.
Answer: B
Rationale: A cane should be held on the stronger side (opposite the weak side) to provide
better balance and support the weight-bearing phase of the affected limb.
,3. Which assessment finding is a component of the Hendrich II Fall Risk Model
but NOT the Morse Fall Scale?
A. Confusion, disorientation, or impulsivity
B. Secondary diagnosis
C. History of falling
D. Gait or transferring ability
Answer: A
Rationale: The Hendrich II specifically assesses for confusion/impulsivity and depression,
whereas the Morse Fall Scale focuses more on history, secondary diagnosis, and
ambulatory aids.
4. Following an inpatient fall, what is the nurse’s first priority action?
A. Complete a detailed incident report for the hospital’s legal team.
B. Notify the primary care provider and the patient’s family.
C. Document the event in the patient’s medical record.
D. Assess the patient for injuries and obtain a set of vital signs.
Answer: D
Rationale: Patient safety is the priority; the nurse must first assess for injuries (like head
trauma or fractures) and stabilize the patient before reporting or documenting.
5. When transferring a patient from a bed to a wheelchair, which action by the
nurse ensures maximum safety?
A. Placing the wheelchair at a 90-degree angle to the bed.
B. Allowing the patient to wear only hospital-issued socks.
C. Lifting the patient under the axillae to provide leverage.
D. Locking the brakes on both the bed and the wheelchair.
Answer: D
Rationale: Locking the brakes prevents the equipment from moving during the transfer,
which is a leading cause of falls during patient mobilization.
, 6. The nurse is caring for an elderly patient with orthostatic hypotension. What
instruction is most important to prevent a fall?
A. ‘Dangle your legs at the bedside for 1-2 minutes before standing.’
B. ‘Drink at least 3 liters of water per day.’
C. ‘Keep your bed in the highest position to make standing easier.’
D. ‘Always walk with your head tilted slightly downward.’
Answer: A
Rationale: Dangling allows the circulatory system to adjust to postural changes,
preventing the sudden drop in blood pressure that causes dizziness and falls.
7. A healthcare provider orders a physical restraint for a combative patient.
What is a legal requirement for the nurse regarding this order?
A. The order must be renewed every 48 hours.
B. The nurse can use a PRN (as needed) order for restraints.
C. The patient’s family must sign a legal waiver before application.
D. The provider must conduct a face-to-face assessment within a specific timeframe (usually 1-4 hours).
Answer: D
Rationale: Federal and accreditation standards require a face-to-face evaluation by a
provider for the use of restraints; PRN orders for restraints are strictly prohibited.
8. Which of the following is considered a ‘restraint alternative’ that the nurse
should attempt first?
A. Applying a four-point leather restraint system.
B. Administering a dose of Lorazepam (Ativan) for agitation.
C. Using a bed alarm or chair pad sensor.
D. Raising all four side rails on the hospital bed.
Answer: C
Rationale: Restraint alternatives are non-restrictive measures, such as bed alarms, sitters,
or diversionary activities, used to maintain safety without physical or chemical restriction.
