A nurse is assessing an older adult client who has just been admitted to the medical-surgical unit and presents with a large amount of abdominal ascites. Client is alert and oriented x3, states that he walks independently at home and normally uses a cane, but forgot to bring it to the hospital. Which of the following measures is important for the nurse to initiate first?

A. Skin safety protocol: While skin safety is important, it is not the immediate priority in this case. The client’s mobility and risk of falls should be addressed first to ensure safety. B. Fall risk protocol: The client has abdominal ascites, which may impair mobility and balance, increasing the risk of falls. Given that the client is using a cane for assistance and forgot it, it is critical to initiate fall risk precautions to prevent any accidents or injuries. C. Bleeding precaution protocol: While important for some clients, there is no immediate indication of bleeding risk in this case. The priority should be addressing the client’s mobility and potential fall risk. D. Sodium restriction diet: While a sodium restriction diet may be important for managing ascites, it is not the first priority in this situation. Ensuring the client's immediate safety is more critical.