A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?
Explanation & Rationale
A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm compromises safety by preventing timely notification if the client attempts to get out of bed unassisted. Bed alarms should remain active at all times for clients on fall precautions. B. Establish an elimination schedule for the client: Scheduling regular toileting reduces the risk of falls by minimizing unassisted trips to the bathroom, which are a common cause of falls, especially in clients with mobility or cognitive impairments. This is an effective and preventive intervention. C. Allow the client to walk unassisted near the nursing station: Clients on fall precautions should not ambulate without assistance or appropriate safety measures, even near the nursing station, as unassisted walking increases the risk of falls. D. Raise all four bed rails on the client's bed: Raising all four bed rails can increase the risk of injury if the client attempts to climb over them and is generally considered a restraint, which requires careful assessment and provider authorization.