3.2 Safety, Risk, Falls & Restraints

A Culture of Client Safety

Client safety is the practical nurse's (PN's) continuous responsibility: anticipate hazards, remove them before harm occurs, and report near-misses honestly. Within the Safe and Effective Care Environment blueprint (28 to 40 percent of the exam), safety questions reward the least-restrictive, most-preventive option and penalize interventions that trade a client's dignity or autonomy for staff convenience. Read each scenario for the answer that both keeps the client safe and preserves independence.

Falls: Risk Assessment and Prevention

Falls are the most common adverse event among hospitalized and long-term-care clients. Begin with a falls risk assessment on admission and after any change in status, using a validated tool such as the Morse Fall Scale or the Hendrich II. The Morse scale scores six factors — history of falling, secondary diagnosis, ambulatory aid, IV or heparin lock, gait, and mental status — to stratify low, moderate, or high risk. Key intrinsic risk factors include age over 65, previous falls, orthostatic hypotension, polypharmacy (especially sedatives, antihypertensives, and diuretics), impaired vision, cognitive impairment, and urinary urgency. Extrinsic factors include wet floors, poor lighting, clutter, unlocked bed wheels, and inappropriate footwear.

Least-restrictive prevention (the exam's preferred answers):

• Keep the bed in the lowest locked position with the call bell within reach.
• Ensure a clear, well-lit path to the bathroom and provide non-slip footwear.
• Implement scheduled toileting or hourly rounding to address urgency before the client mobilizes alone.
• Use bed or chair alarms, and place high-risk clients near the nursing station.
• Review medications with the team and teach slow position changes for orthostatic hypotension.

Watch the traps: a dimly lit room and a room placed far from the station actually increase fall risk, and restraints are never a first-line fall measure — they raise the risk of serious injury, entrapment, and death.

Least-Restraint Policy and Alternatives

Canadian practice follows a least-restraint, ideally restraint-free, philosophy. A restraint is any device, medication, or environmental limit that restricts a client's free movement: physical (limb restraints, belts, vests), chemical (a sedative used to control behaviour rather than to treat a diagnosed condition), or environmental (seclusion). Restraints are a last resort, used only to prevent imminent serious harm when all alternatives have failed.

Try alternatives first: reorientation, distraction and meaningful activity, family presence, moving the client closer to the station, meeting pain, toileting, or hunger needs, covering IV sites and tubing so they are out of sight, and lowering environmental triggers such as noise and glare.

Safe Use of Restraints

When a restraint is genuinely unavoidable, the standards the exam tests are strict:

1. Obtain a prescriber order — except in a true emergency, when the order is obtained immediately after application — specifying type, reason, and duration; a standing PRN (as-needed) restraint order is prohibited.
2. Use the least restrictive effective device, secured with a quick-release knot to the bed frame (never a side rail) and loose enough to admit two fingers.
3. Reassess frequently (commonly every 1 to 2 hours) for circulation, skin integrity, positioning, toileting, hydration, and continued need, and release and exercise the limb on a schedule.
4. Document the behaviour, the alternatives already tried, consent or notification, the device used, and every ongoing assessment. Remove the restraint as soon as the client is safe.

Workplace Safety and WHMIS

The PN's own safety matters too. WHMIS (Workplace Hazardous Materials Information System), aligned with the global GHS, governs hazardous chemicals through three elements: labels, Safety Data Sheets (SDS), and worker education. For any chemical spill or exposure, the SDS is the authoritative source for hazards, required PPE, safe cleanup, and first aid — not the medication record, the care plan, or the staffing sheet. Other essentials: safe patient handling with mechanical lifts checked for correct sling size, intact (non-frayed) straps, and a client weight within the rated capacity (two staff are often required); proper body mechanics; and sharps safety — never recap needles, the leading cause of needlestick injury, and dispose of them directly into a puncture-resistant sharps container that is replaced before it overfills.

Fire Safety and Incident Prevention

Memorize two fire acronyms: RACE — Rescue or remove clients, Alarm, Contain (close doors and windows), Extinguish or Evacuate — and PASS for the extinguisher — Pull the pin, Aim at the base, Squeeze, Sweep. Rescuing clients comes first; never restrain clients in bed during a fire. Because oxygen vigorously supports combustion, immediately remove ignition sources such as smoking materials or sparks near an oxygen source. Finally, incident or occurrence reports record any error or near-miss factually and objectively to drive quality improvement; they are not filed in the client's chart and are never used punitively, so reporting honestly is a professional duty.

Worked Safety Scenario

Consider a common REx-PN vignette: an 82-year-old client with new-onset confusion is repeatedly climbing over the side rails at night. The tempting but wrong answer is to raise all four rails or apply a restraint — four raised rails are legally considered a restraint and increase entrapment and fall-from-height injury. The correct nursing sequence is to first assess for a reversible cause (pain, full bladder, infection, medication effect, hypoxia), then apply least-restrictive measures: lower the bed to its lowest position, add a bed alarm, provide scheduled toileting, place the client near the station, and enlist family presence. Only if these fail and the client is at imminent risk does a restraint become appropriate, and only with a prescriber order and frequent reassessment. This progression — assess, prevent, then restrain as a last resort — is the pattern the exam rewards on nearly every safety item.