A nurse on a medical surgical unit is collecting data from an older adult client who has a large amount of abdominal ascites. The client is alert and oriented x3 and states that they walk independently at home and normally use a cane but forgot to bring it to the hospital. Which of the following measures are important for the nurse to initiate first?

A. Skin safety protocol: Skin integrity measures are important for clients with ascites but are not the immediate first action for fall risk. B. Fall risk protocol: Forgetting an assistive device plus altered center of gravity from large ascites increases fall risk - initiating fall precautions (assist with ambulation, provide call light, bedside assistive devices) is the priority for safety. C. Bleeding precaution protocol: Bleeding precautions may be relevant for cirrhosis with coagulopathy, but fall prevention is more immediately protective for this ambulatory-risk situation. D. Sodium restriction diet: Dietary sodium restriction helps long-term ascites management but is not the first immediate safety intervention.