The unit educator audits an inpatient fall-prevention plan. Which actions require follow-up? Highlight the actions that do not provide current, individualized fall protection.
Highlight in Table
Choose your responses, then check the answer.
Explanation
A high unlocked bed, reliance on an alarm instead of rounding, and failure to update the plan after new dizziness require follow-up. Fall prevention must be reassessed, individualized, and performed consistently.
Quick answer Highlight leaving the bed high and unlocked, using an alarm instead of purposeful rounding and toileting, and delaying a plan update after new dizziness. Each action leaves a known fall pathway open.
Why this is correct Fall prevention is a cycle: assess current risk, match interventions to that risk, and carry them out reliably. A locked low bed reduces environmental danger, while rounding and toileting address why the client may rise. New dizziness changes risk immediately, so keeping an old plan or relying on an alarm alone does not provide individualized prevention.[2]
Easy analogy or mental picture Think of a rain plan that must match today’s weather. A yesterday plan or an alarm that only announces rain cannot keep someone dry; current conditions and active protection are needed. The picture maps reassessment and action, not every fall cause.
Memory hook Assess, tailor, perform, reassess.
NCLEX decision rule When fall risk or the client condition changes, think updated individualized protection; check bed safety, toileting, mobility assistance, medication effects, and whether the plan is actually being followed.
Why the other choices are wrong Reassessment, a bedside-specific plan, reachable items, ordered mobility support, medication review, and teach-back all actively reduce the client’s identified risks. They support rather than substitute for consistent nursing observation.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
AHRQ: Fall TIPS Patient-Centered Fall Prevention ToolkitAgency for Healthcare Research and Quality