A nurse is caring for a client who is at risk for a fall because of orthostatic hypotension. Which of the following actions should the nurse take?

A. Keep all four of the side rails raised on the client's bed: Raising all four side rails can increase the risk of injury if the client attempts to climb over them. Full side rails are not a recommended fall-prevention strategy for clients with orthostatic hypotension. B. Check the client every 4 hr to evaluate their need to use the restroom: Checking every 4 hours may not be frequent enough to prevent falls related to sudden episodes of dizziness or urgency. More proactive measures, such as assisting with ambulation, are safer for clients at risk. C. Instruct the client to stand in place when beginning ambulation: Having the client stand in place for a few moments allows blood pressure to stabilize before walking, reducing the risk of dizziness and falls caused by orthostatic hypotension. This is a key intervention for fall prevention in at-risk clients. D. Maintain the client's bed at the nurse's waist level: The bed height should be adjusted to facilitate safe transfers, typically at the level that allows feet to touch the floor and promotes stability. Keeping the bed at the nurse's waist level does not specifically prevent falls due to orthostatic hypotension.