# Review the client's changing fall risk during the shift and select the prevention plan that matches the new risk factors.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393501&lang=en  
> language: en  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## Question

Review the client's changing fall risk during the shift and select the prevention plan that matches the new risk factors.

| Time | Data |
| --- | --- |
| 0800 | Client reports being independent at home. Walks to the bathroom with standby assistance; call light is used appropriately. |
| 1000 | After an antihypertensive dose, the client reports dizziness on standing. BP changes from 132/74 mm Hg supine to 104/62 mm Hg standing. |
| 1130 | After receiving a prescribed opioid, the client is drowsy and unsteady. The client attempts to climb over the bedrail to reach the bathroom urgently. |

Q1. How should the nurse interpret the trend?

Fall risk remains low because the client was independent at home
The bedrail attempt proves that restraints are required
Fall risk has increased and the prevention plan requires immediate revision

Q2. Which plan best matches the client's current risk factors?

Place a fall-risk sign and continue unassisted bathroom trips
Reassess and communicate risk; provide assisted scheduled toileting, a low locked bed, clear access to the call light, and review dizziness and medications
Apply restraints routinely and stop all mobility for the rest of the admission

Q3. Which intervention most directly addresses the trigger for the 1130 unsafe transfer?

Remove the call light so the client will rest
Ask the client to avoid fluids for the entire day
Offer frequent assisted toileting and respond promptly to bathroom needs

## Explanation

Fall risk is dynamic. Baseline independence does not protect the client after orthostatic symptoms, sedating medication, unsteady gait, and an attempted unassisted transfer develop. The nurse should reassess and communicate the changed risk, identify the client's specific contributors, and implement a tailored plan such as assisted scheduled toileting, call-light and personal-item access, appropriate footwear, a low and locked bed, clear pathways, and medication or orthostatic review. A generic fall-risk sign alone is not an individualized plan, and physical restraints can increase injury and are not a routine first-line prevention strategy.

## In-depth explanation

Trend to recognize
The client's risk rises after dizziness, medication exposure, gait change, and an attempt to toilet alone. Yesterday's or admission status is no longer the correct plan.

Prevention sequence
Reassess risk, identify the person's current risk factors, build a tailored plan, and carry it out consistently with the client and team.

Tailored actions
Assisted scheduled toileting directly addresses urgency and unsafe transfers; a low locked bed, clear path, reachable call light, footwear, and review of dizziness and medications address additional contributors.

Why the alternatives fail
A wristband or sign communicates risk but does not prevent a fall by itself. Telling the client to remain in bed without a toileting plan does not address the trigger. Routine restraints can cause harm and do not replace individualized prevention.

Source
1AHRQ Fall TIPS Patient-Centered Fall Prevention Toolkit
22026 NCLEX-RN Test Plan

## Clinical scenario

Medical-surgical unit
An older adult was independent at home and is admitted for dehydration. The nurse reassesses fall risk as treatments, symptoms, and mobility change.

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