2025-08-15·7 min read·Category Guides
Fall Prevention in Nursing: NCLEX Review
Risk factors, assessment tools, and evidence-based interventions for preventing patient falls.
Risk Factors
- Age >65, history of previous falls
- Medications: sedatives, opioids, antihypertensives, diuretics
- Altered mental status, confusion, dementia
- Impaired mobility, weakness, unsteady gait
- Urinary urgency/frequency
- Environmental hazards: wet floors, poor lighting, clutter
Assessment Tools
- Morse Fall Scale: Scores 0-125. ≥45 = high risk
- Hendrich II: Alternative fall risk assessment
- Assess fall risk on admission, with changes in condition, and after any fall
Prevention Interventions
- Call light within reach at all times
- Bed in lowest position, wheels locked
- Non-skid footwear
- Adequate lighting, clear pathways
- Bed alarm for high-risk clients
- Toileting schedule
- Medication review (reduce sedatives if possible)
- Assistive devices (walker, cane) within reach
After a Fall
- Assess the client for injury
- Do NOT move until assessed
- Notify the provider
- Document and complete incident report
Review our Safe Care study guide and Safe Care flashcards.