The Emergency Department Nurse Admits a Patient Following a Motor

The emergency department nurse admits a patient following a motor vehicle collision.Vital signs include blood pressure 70/50 mm Hg,heart rate 140 beats/min,respiratory rate 36 breaths/min,temperature 101° F and oxygen saturation (SpO₂) 95% on 3 L of oxygen per nasal cannula.Laboratory results include hemoglobin 6.0 g/dL,hematocrit 20%,and potassium 4.0 mEq/L.Based on this assessment,what is most important for the nurse to include in the patient's plan of care?

A) Insertion of an 18-gauge peripheral intravenous line
B) Application of cushioned heel protectors
C) Implementation of fall precautions
D) Implementation of universal precautions