A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

A. Allow the client to walk unassisted near the nursing station: Even in a monitored area, allowing an at-risk client to ambulate unassisted increases the chance of falling. Clients on fall precautions should always have supervision or assistive devices during ambulation. B. Establish an elimination schedule for the client: Scheduled toileting reduces the risk of unassisted attempts to get out of bed, a common cause of falls in hospitalized clients. It supports safety by addressing one of the most frequent fall triggers. C. Raise the four bed rails on the client’s bed: Using all four bed rails can be considered a form of restraint and may increase fall risk if the client tries to climb over them. Two or three side rails are safer and still provide support. D. Silence the bed alarm when visitors are at the client’s bedside: Bed alarms are a key fall prevention tool. Silencing them reduces their effectiveness and can delay the response to unsupervised movement, even if visitors are present.