# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=495943&lang=en  
> language: en  
> subject: Standard/Transmission-Based Precautions/Surgical Asepsis  
> category: SIPC

## Question

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.

| Plan element | Observed action |
| --- | --- |
| Risk review | Reassess fall risk after a new sedating medication is started |
| Bed setup | Leave the bed high and unlocked so staff can transfer quickly |
| Care plan | Post the client-specific mobility and toileting plan at bedside and review it with each caregiver |
| Environment | Keep the call light and needed personal items within reach |
| Mobility | Use the ordered assistance level and gait device for walking |
| Alarm use | Let the bed alarm replace rounding and scheduled toileting |
| Medication review | Ask the team to review drugs that increase dizziness |
| Client teaching | Ask the client to call before standing and verify teach-back |
| Condition change | Keep yesterday’s plan after new dizziness until tomorrow |

## 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.

## In-depth explanation

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

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