What step should a nurse take when they suspect a client is at risk for falls?

When a nurse suspects that a client is at risk for falls, the most appropriate step is to initiate a fall prevention protocol. This proactive measure involves implementing specific strategies and interventions designed to minimize the risk of falls for the client. Such protocols may include conducting a thorough fall risk assessment, using assistive devices, ensuring the environment is free of hazards, and providing patient education about safety.

Initiating a fall prevention protocol is crucial because it not only addresses the immediate risk but also establishes a framework for ongoing assessment and intervention. It ensures that all staff members are aware of the client's fall risk and can contribute to maintaining a safe environment. By engaging in this comprehensive approach, the nurse helps to protect the client from potential injury and encourages collaborative care among the healthcare team.

While documenting the fall risk assessment findings contributes to the overall understanding of the client's status, it does not take direct action to prevent falls. Monitoring the client only during medication rounds fails to provide continuous oversight needed to mitigate fall risks. Transferring the client to a more secure unit might be necessary in some situations; however, it is more of a reactive measure rather than a primary preventative strategy. Therefore, initiating a fall prevention protocol is the optimal and most responsible choice right from the beginning.