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

Rationale: A. Clients on fall precautions should not ambulate unassisted. Even if the client is near the nursing station (which may improve observation), they still require assistance, supervision, or assistive devices to reduce fall risk. B. An elimination schedule (also called scheduled toileting or timed voiding) helps prevent falls by anticipating the client’s need to use the bathroom. Many falls occur when clients rush to the bathroom due to urgency. Planning regular toileting times reduces unsupervised ambulation and improves safety. C. Bed alarms are a critical safety measure for clients at risk for falls. Silencing or disabling them increases the risk of unnoticed unassisted movement, which can lead to injury. Alarms should remain active unless the client is being safely mobilized with supervision. D. Raising all four side rails is considered a restraint in many situations and can increase risk of injury if the client attempts to climb over them. It may also increase agitation and does not eliminate fall risk. Safer alternatives include low bed positioning and appropriate supervision.