Safety and fundamentals questions test the judgment that keeps clients from harm, and they show up all over the NCLEX. Work through these 10 practice questions on fall prevention, restraints, fire safety (RACE and PASS), seizure precautions, patient identification, and safe patient handling, each with a full rationale that explains why every option is right or wrong.
Safety Fundamentals: Falls, Restraints, Fire & More
Safety is the backbone of NCLEX. When a question asks what to do first, screen for physiological threat, then the safest, least-restrictive action. Fall prevention is proactive: identify high-risk clients (advanced age, history of falls, sedatives/benzodiazepines, orthostatic hypotension, mobility or cognitive deficits) and score risk with a validated tool such as the Morse Fall Scale or Hendrich II Fall Risk Model, then keep the bed low and locked, call light and personal items within reach, nonskid footwear on, pathways clear and well lit, and use bed/chair alarms plus purposeful hourly rounding. After any fall, assess the client fully before moving them.
Restraints are a last resort used only after less-restrictive alternatives fail. They require a time-limited provider order (PRN and standing restraint orders are prohibited), the least restrictive device, ties secured to the movable bed frame (never a side rail) with a quick-release knot, and scheduled checks of circulation, skin, ROM, toileting, and nutrition at least every 2 hours. Violent/behavioral restraints carry shorter renewal limits, require a face-to-face evaluation, and call for continuous monitoring.
Memorize the emergency mnemonics. Fire: RACE (Rescue, Alarm, Confine, Extinguish/Evacuate) and PASS (Pull, Aim at the base, Squeeze, Sweep); turn off oxygen near a fire, and remember the fire triangle of heat, fuel, and oxygen. Patient identification always uses at least two identifiers (full name and date of birth), never the room number. For seizures, protect and position side-lying, pad rails, keep suction and oxygen ready, time the event, and never restrain or put anything in the mouth. Protect yourself and clients with mechanical lifts and good body mechanics, and know that syrup of ipecac is obsolete, so call Poison Control.
Braden Scale scoring and the NPIAP pressure injury stages are summarized in our pressure injury staging guide.
Fundamentals & Safety NCLEX Practice Questions
Question 1 · Fall Prevention
A nurse is reviewing a medical unit's client assignment to identify who is at highest risk for a fall. Which client should the nurse prioritize for fall-prevention interventions?
- A An 82-year-old admitted after a syncopal episode who takes lorazepam at bedtime and has orthostatic hypotension
- B A 40-year-old recovering from an uncomplicated laparoscopic appendectomy who ambulates independently in the hallway
- C A 25-year-old with a stable fractured clavicle, immobilized in a sling, who is awaiting discharge paperwork
- D A 55-year-old with well-controlled hypertension, normal orthostatic vital signs, and no mobility or cognitive deficits
Show answer & rationale
Correct answer: A
The 82-year-old is the priority. A recent syncopal episode signals a near-fall/history-of-falling picture, bedtime lorazepam produces sedation and impaired balance, and orthostatic hypotension causes lightheadedness on standing that compounds the syncope. This client stacks intrinsic factors (advanced age, orthostasis) and an extrinsic sedating drug, warranting layered interventions: bed low and locked, a bed/chair alarm, nonskid footwear, assisted transfers, and frequent purposeful rounding. Match the tool to the claim: the Morse Fall Scale scores only six items — history of falling, a secondary diagnosis, use of an ambulatory aid, an IV/heparin lock, gait/transferring, and mental status; it does NOT award points for age or for sedating medications per se. The Hendrich II Fall Risk Model is the instrument that specifically scores benzodiazepines and antiepileptics (and other factors such as confusion, depression, altered elimination, dizziness/vertigo, and an impaired get-up-and-go). Either way, this client's syncope history, secondary diagnosis, and unsteadiness drive the highest score. The independently ambulating post-appendectomy client (choice B) has an intact gait with no sedation or fall history, so risk is low despite recent surgery. The young client with a stable clavicle fracture awaiting discharge (choice C) is mobile with no orthostasis or sedation. The client with controlled hypertension, normal orthostatic vital signs, and no mobility or cognitive deficits (choice D) carries no meaningful risk factors. Clinical pearl: picture the classic high-risk faller as old, orthostatic, on sedatives, and unsteady — the more of those a client stacks, the higher the score and the more layered the interventions. Age alone or a fracture alone rarely makes someone the priority; it is the combination of intrinsic factors (age, orthostasis, cognition) and extrinsic factors (sedatives, tethers) that flags the true high-risk faller.
Question 2 · Fall Prevention
A nurse is implementing fall-prevention measures for a confused older adult at high risk for falls. Which interventions should the nurse include? Select all that apply.
- A Keep all four side rails raised at all times to prevent the client from getting out of bed
- B Keep the bed in the lowest position and lock the wheels
- C Place the call light and personal items within the client's reach
- D Apply a vest restraint routinely for any client older than 65
- E Provide nonskid footwear when the client is out of bed
- F Ensure a clear, well-lit pathway to the bathroom
Show answer & rationale
Correct answer: B, C, E, F
Correct measures are keeping the bed low and locked, keeping the call light and personal items within reach, providing nonskid footwear, and maintaining a clear, well-lit path to the bathroom. A low, locked bed shortens the fall distance and prevents rolling. Items within reach reduce risky reaching and unassisted transfers, and a call light lets the client summon help. Nonskid footwear improves traction, and a clear, lit pathway prevents tripping during nighttime bathroom trips, a common fall setting. Raising all four side rails is incorrect: four raised rails are considered a restraint because they prevent voluntary exit, and clients often climb over them and fall from a greater height. Routinely applying a vest restraint to anyone over 65 is wrong on two counts: restraints are a last resort used only after less-restrictive measures fail, and age alone is never justification. Restraints require a time-limited provider order and can increase injury, agitation, and deconditioning. Clinical pearl: fall prevention is about a safe environment and purposeful hourly rounding (address the 4 Ps: pain, potty, position, possessions), not about restricting movement. Least-restrictive, proactive strategies keep the client safe while preserving mobility and dignity.
Question 3 · Restraints
A confused client keeps pulling at an IV line and a nasogastric tube. Which action by the nurse best reflects safe, current restraint practice?
- A Apply soft wrist restraints as the first intervention to stop the client from removing the devices
- B Try less-restrictive measures first, such as reorientation, camouflaging the tubing, and family presence
- C Use a PRN restraint order that was written on admission so restraints can be applied whenever needed
- D Secure the restraint ties to the side rails so the client cannot reach the IV line or the nasogastric tube
Show answer & rationale
Correct answer: B
The correct action is to try less-restrictive measures first, such as reorientation, a bed alarm, camouflaging or securing the tubing under a gown, and having family present. Restraints are a last resort applied only after alternatives fail, because they increase agitation, injury, aspiration, deconditioning, and even death. Applying wrist restraints as the first intervention skips this required step and violates least-restrictive standards. Using a PRN restraint order is prohibited: standing and as-needed restraint orders are not allowed. Restraints require an individualized, time-limited provider order, and behavioral/violent restraints additionally require a face-to-face evaluation and carry shorter renewal windows. Securing ties to the side rails is dangerous; if the rail is lowered or moved, the restraint tightens and can cause injury or strangulation. Ties must be secured to the movable bed frame with a quick-release knot so the device moves with the bed and can be released instantly in an emergency. Clinical pearl: think 'least restrictive, time-limited order, quick-release to the bed frame.' If a strategy protects the line without limiting the client's freedom, it is always preferred, and restraints are only justified when the client is an imminent danger to self or others and nothing less has worked.
Question 4 · Restraints
A nurse must apply restraints to a client after less-restrictive measures have failed. Which actions reflect safe restraint application and monitoring? Select all that apply.
- A Obtain a time-limited provider order before, or immediately after emergency, application
- B Tie the restraint to the side rail with a secure square knot so it will not loosen
- C Assess circulation, skin integrity, and range of motion at least every 2 hours
- D Secure the restraint ties to the movable bed frame using a quick-release knot
- E Choose the most restrictive device available to ensure maximum safety
- F Provide toileting, nutrition, and hydration on a scheduled basis
Show answer & rationale
Correct answer: A, C, D, F
Safe restraint use requires a time-limited provider order (obtained before application, or immediately after in a true emergency), securing ties to the movable bed frame with a quick-release knot, assessing circulation, skin, and ROM about every 2 hours, and providing scheduled toileting, nutrition, and hydration. These protect against the major restraint harms: impaired perfusion, skin breakdown, contractures, aspiration, dehydration, and loss of dignity, while continuous monitoring guards against strangulation and asphyxiation. Tying the restraint to the side rail with a square knot is incorrect and dangerous: a side rail can be lowered or dislodged, tightening the restraint, and a square (non-quick-release) knot cannot be freed rapidly in an emergency. Ties must go to the bed frame with a knot that releases with a single pull. Choosing the most restrictive device is wrong; the standard is the least restrictive device that maintains safety. Clinical pearl: PRN and standing restraint orders are prohibited, and behavioral/violent restraints require a face-to-face evaluation with shorter renewal limits than medical/surgical restraints. Remember the safety triad: right order, right knot to the bed frame, and right checks every 2 hours.
Question 5 · Fire Safety
A nurse discovers a fire in a trash can inside an occupied client room. Using the RACE protocol, which action should the nurse take first?
- A Activate the facility fire alarm system
- B Confine the fire by closing all the doors on the unit
- C Rescue any clients who are in immediate danger from the fire
- D Attempt to extinguish the fire with the nearest fire extinguisher
Show answer & rationale
Correct answer: C
The first step in RACE is Rescue: move any client in immediate danger away from the fire. Because a client is in the room with the fire, protecting human life comes before anything else. RACE stands for Rescue, Alarm, Confine, Extinguish/Evacuate, performed in that order. Activating the alarm is essential but comes second, after removing the client from immediate danger; the alarm summons help but does not, by itself, protect the person next to the flames. Confining the fire by closing doors is the third step and slows the spread of smoke and fire once people are safe and the alarm is pulled. Extinguishing is last and only appropriate for a small, contained fire when the client is safe, the alarm is activated, and it is safe to do so; if the fire is large or spreading, evacuate instead. Clinical pearl: RACE tells you the order, and 'Rescue first' means life safety over property every time. If oxygen is running near the fire, turn it off, because oxygen is one leg of the fire triangle (heat, fuel, oxygen) and feeds the flames. When you do use the extinguisher, follow PASS: Pull, Aim at the base, Squeeze, Sweep.
Question 6 · Fire Safety
A nurse must use a fire extinguisher on a small, contained fire. Which technique reflects correct use of the PASS mnemonic?
- A Pull the pin, aim at the top of the flames, squeeze the handle, and sweep side to side
- B Aim just above the flames and discharge the agent in short, controlled bursts
- C Pull the pin, then sweep side to side across the top of the flames while squeezing
- D Pull the pin, aim at the base of the fire, squeeze the handle, and sweep side to side
Show answer & rationale
Correct answer: D
The correct technique is to Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep side to side, which is the PASS mnemonic. Aiming at the base is critical because that is where the fuel is; spraying the flames themselves wastes the extinguishing agent and does not stop the fire from being fed. Aiming at the top of the flames is wrong for the same reason: pulling the pin, squeezing, and sweeping are correct, but the aim is off. Aiming just above the flames misses the fuel source entirely. Sweeping across the top of the flames also targets the wrong area and will not smother the fire. Clinical pearl: 'Hit the base, not the blaze.' Remember PASS pairs with RACE: RACE tells you what to do in a fire (Rescue, Alarm, Confine, Extinguish/Evacuate), and PASS tells you how to use the extinguisher during the Extinguish step. Only attempt to extinguish a small, contained fire after clients are rescued and the alarm is activated, and if oxygen is nearby, shut it off first, since oxygen is one side of the fire triangle (heat, fuel, oxygen) and accelerates combustion.
Question 7 · Patient Identification
A nurse is preparing to administer a scheduled medication. Which method correctly meets Joint Commission requirements for identifying the client?
- A Confirm the client's room and bed number match the medication administration record
- B Ask 'Are you Mr. Jones?' and give the medication when the client nods yes
- C Verify the client's full name and date of birth against the medication record
- D Match the client to the bed assignment listed on the unit whiteboard before giving the dose
Show answer & rationale
Correct answer: C
The correct method is to verify the client's full name and date of birth, using at least two identifiers matched against the medication administration record or armband. Joint Commission patient-identification requirements (formerly National Patient Safety Goal NPSG.01.01.01) call for two independent identifiers to ensure the right care goes to the right person. Using the room or bed number is unsafe because clients are moved, and locations are not unique to a person. Asking 'Are you Mr. Jones?' invites error: a confused, sedated, hard-of-hearing, or eager-to-please client may answer yes to any name. Instead, use open-ended prompts ('Please tell me your name and date of birth') and verify against the armband. Matching to a whiteboard assignment relies on a location and a potentially outdated board, not on the client's identity. Clinical pearl: acceptable identifiers include full name, date of birth, and a medical record number; the room number is never an acceptable identifier. Always compare the client's stated information and armband to the order or record before medications, blood, procedures, or specimen collection. Two matching identifiers, actively verified, protect against wrong-patient errors, one of the most preventable and consequential mistakes in nursing.
Question 8 · Seizure Precautions
A hospitalized client begins to have a generalized tonic-clonic seizure. Which nursing actions are appropriate? Select all that apply.
- A Insert a padded tongue blade between the client's teeth
- B Protect the client's head and loosen restrictive clothing
- C Restrain the client's extremities to stop the movements
- D Turn the client to a side-lying position
- E Ensure suction and oxygen are available at the bedside
- F Time the duration of the seizure
Show answer & rationale
Correct answer: B, D, E, F
Appropriate actions are turning the client side-lying, protecting the head and loosening restrictive clothing, timing the seizure, and keeping suction and oxygen at the bedside. Side-lying positioning promotes drainage of secretions and prevents aspiration if the client vomits. Protecting the head (a pillow or padding, easing the client to the floor if standing) and loosening tight clothing prevent injury and ease breathing. Timing matters because a seizure lasting 5 minutes or longer, or repeated seizures without recovery, signals status epilepticus, a medical emergency. Suction and oxygen ready at the bedside are standard seizure precautions for airway management afterward. Inserting a padded tongue blade or any object into the mouth is contraindicated: it can break teeth, obstruct the airway, or injure the nurse, and it does not prevent tongue biting, which usually occurs at onset. Restraining the extremities is also wrong, as holding the client down can cause fractures, dislocations, or muscle injury; instead, clear the area and guide movements without restricting them. Clinical pearl: for seizures, 'protect, position, time, and never put anything in the mouth or hold the client down.' Also pad the side rails in advance for at-risk clients, and stay with the client, calling for help rather than leaving.
Question 9 · Body Mechanics
A nurse must reposition a large, immobile client higher in the bed. Which action best reflects safe client handling and body mechanics?
- A Use a mechanical or powered lift and obtain adequate assistance
- B Manually lift the client with one other nurse to save time
- C Bend at the waist and keep the load away from the body for better leverage
- D Twist at the trunk while pulling the client toward the head of the bed
Show answer & rationale
Correct answer: A
The safest action is to use a mechanical or powered lift (or friction-reducing device) and get adequate help. Current safe client-handling standards call for assistive equipment and team lifts rather than manual lifting to protect both the client and the nurse from injury; musculoskeletal injuries from manual client handling are a leading cause of nurse disability. Manually lifting with one other nurse to save time risks injury to staff and the client and ignores available equipment; speed never justifies unsafe lifting. Bending at the waist and holding the load away from the body violates core body-mechanics principles: it strains the back and reduces control. Instead, bend at the knees and hips, keep the back straight, and keep the load close to your center of gravity. Twisting at the trunk while pulling is a classic mechanism for back injury; you should pivot with your feet and avoid rotation of the spine. Clinical pearl: maintain a wide base of support, bend your knees, keep the load close, avoid twisting, and use mechanical lifts plus teamwork. When in doubt, 'lift with the legs, get help, and let the equipment do the work.' Protecting yourself is part of protecting your clients, since an injured nurse cannot deliver care.
Question 10 · Poison & Equipment Safety
A parent calls the clinic stating that their 2-year-old just swallowed an unknown amount of liquid household cleaner. What is the nurse's most appropriate instruction?
- A Administer syrup of ipecac immediately to induce vomiting
- B Contact Poison Control at 1-800-222-1222 right away for guidance
- C Give the child saltwater to make him vomit the cleaner
- D Have the child swallow activated charcoal at home without further direction
Show answer & rationale
Correct answer: B
The correct instruction is to contact Poison Control (1-800-222-1222) immediately for expert, exposure-specific guidance. Poison Control can advise on whether the substance is caustic, what symptoms to watch for, and whether the child needs emergency evaluation. Administering syrup of ipecac is incorrect and outdated: ipecac is no longer recommended and is considered obsolete because induced vomiting can cause aspiration and, with caustic substances, re-injures the esophagus on the way back up. Giving saltwater to induce vomiting is dangerous on two counts: it forces vomiting (contraindicated, especially with caustics) and can cause life-threatening hypernatremia in a small child. Giving activated charcoal at home without direction is inappropriate, as charcoal does not bind all substances (including many caustics and alcohols), can cause aspiration, and should only be used under professional direction. Clinical pearl: for any poisoning, the modern first step is 'do not induce vomiting, call Poison Control.' Keep the product container handy to report the ingredients and concentration. Also reinforce equipment safety at home and in the hospital: never use frayed electrical cords, unplug devices by grasping the plug (not the cord), and keep cleaners and medications locked away from children.
Want more practice questions? Create a free NCLEX Key account — NCLEX-style questions with a full rationale on every answer. No credit card.
Start practicing free →
Fundamentals & Safety FAQ
What is the correct order for RACE and PASS in a fire?
RACE sets the priorities: Rescue anyone in immediate danger first, then Activate the alarm, Confine the fire by closing doors, and Extinguish or Evacuate. PASS is how you use the extinguisher: Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep side to side. Life safety (Rescue) always comes before property, and if oxygen is in use near the fire, turn it off because oxygen feeds the flames.
Do restraints require a provider order, and how are they applied safely?
Yes. Restraints require an individualized, time-limited provider order; PRN and standing restraint orders are prohibited, and violent/behavioral restraints also require a face-to-face evaluation with shorter renewal limits. Use the least restrictive device only after less-restrictive measures fail. Secure the ties to the movable bed frame (never a side rail) with a quick-release knot, and check circulation, skin, range of motion, toileting, and nutrition at least every 2 hours; violent/behavioral restraints additionally require continuous monitoring.
What should I do during a client's seizure?
Stay with the client and call for help. Turn the client side-lying to protect the airway, ease them to the floor if needed, protect the head, and loosen tight clothing. Time the seizure, and keep suction and oxygen ready at the bedside. Do not restrain the client and do not put anything in the mouth. A seizure lasting 5 minutes or longer signals status epilepticus, a medical emergency.
How many identifiers should I use to identify a client, and can I use the room number?
Use at least two identifiers, such as the client's full name and date of birth, verified against the armband and the record. Never use the room or bed number, because clients get moved and locations are not unique to a person. Avoid yes/no questions like 'Are you Mr. Smith?'; instead ask the client to state their name and date of birth so a confused or sedated client cannot mistakenly confirm the wrong identity.