# A nurse is conducting morning rounds on adult medical-surgical clients. Which clients should the nurse identify as high fall risk requiring intervention? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is conducting morning rounds on adult medical-surgical clients. Which clients should the nurse identify as high fall risk requiring intervention? Select all that apply.

1

A 32-year-old postoperative day 1 from elective laparoscopic appendectomy ambulating independently

2

A 56-year-old with a history of stroke who has left-sided hemiparesis

3

A 78-year-old taking three antihypertensive medications who reports dizziness when standing

4

A 45-year-old with well-controlled type 2 diabetes ambulating without assistance

5

An 84-year-old with delirium and an indwelling urinary catheter

## Explanation

High fall risk indicators include orthostatic hypotension (multiple antihypertensives plus dizziness), motor or sensory deficits (stroke with hemiparesis), and altered cognition with tethering devices (delirium plus indwelling catheter). The 32-year-old with a low-impact laparoscopic recovery and the 45-year-old with controlled diabetes ambulating independently are not high risk based on the data given.

## In-depth explanation

Clinical Judgment
NCLEX fall risk multipliers: age >65, polypharmacy, orthostasis, prior fall, stroke/hemiparesis, delirium/dementia, tethering devices. Standardized tools: Morse Fall Scale, Hendrich II, STRATIFY. Score above unit cutoff triggers a high-risk care bundle.

Memory Tip
Fall risk: Age + Meds + Mobility + Mind + Tubes

KR vs US
The Joint Commission and Korean Hospital Accreditation both require a validated fall risk tool on admission and at each shift. Korean tertiary hospitals commonly use Morse Fall Scale, the same tool widely used in the US.

## Clinical scenario

Clinical Practice Guide
High fall risk care bundle (Joint Commission + AHRQ):
- Yellow fall-risk wristband and door sign
- Bed in lowest position, side rails up x 2 (not all 4 — counts as restraint)
- Bed and chair alarms for cognitively impaired
- Non-slip footwear on at all times
- Call light within reach; reorient frequently
- Hourly purposeful rounding covering pain, position, potty, possessions
- Toilet on a schedule for clients with diuretics or urinary urgency
- Postural BP and orthostatic safety teaching

Caution
Indwelling catheters and IV lines are tethering hazards that increase fall risk. Discontinue at the earliest opportunity. Polypharmacy review (especially benzodiazepines, opioids, antihypertensives) is a high-yield prevention strategy.

## Key concepts

- **Morse Fall Scale** — Validated bedside fall risk tool with 6 items: history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, mental status. Score 0-125. Cutoffs vary by institution (commonly low <25, moderate 25-44, high ≥45). Reassessed each shift.
- **Orthostatic hypotension** — Drop in systolic BP ≥20 mmHg or diastolic ≥10 mmHg within 3 minutes of standing. Causes: dehydration, antihypertensives, autonomic dysfunction, prolonged bed rest. Major contributor to falls in older adults. Teach slow position changes and hydration.
- **Tethering hazard** — Any device tethering the client to the bedside (urinary catheter tubing, IV lines, oxygen tubing, telemetry leads, sequential compression devices). Increases fall risk by limiting safe ambulation paths. Remove at earliest clinical opportunity.

## Related questions

- [A nurse on a medical-surgical unit reviews the morning labs for a 67-year-old male client …](https://mymerci.kr/pages/nclex_q.php?qn_id=361711&lang=en)
- [A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following ton…](https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=en)
- [A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit…](https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=en)
- [A 72-year-old male client is receiving a continuous IV heparin infusion for a left lower-e…](https://mymerci.kr/pages/nclex_q.php?qn_id=362064&lang=en)
- [A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=363990&lang=en)
- [A nurse is teaching a 65-year-old client recovering from open upper abdominal surgery how …](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=en)
- [A nurse is administering a unit of packed red blood cells to a client. Twenty minutes afte…](https://mymerci.kr/pages/nclex_q.php?qn_id=364947&lang=en)
- [A nurse is evaluating a 35-year-old client during a routine outpatient visit 4 years after…](https://mymerci.kr/pages/nclex_q.php?qn_id=368098&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._