What Routine Fall Prevention Measures Should the Nurse Institute for All

What routine fall prevention measures should the nurse institute for all clients? Select all that apply.

A) Making sure wheelchairs are locked when not being used by the client.
B) Assisting with ambulation whenever needed
C) Making sure spills are cleaned up immediately
D) Recording the results of a falls assessment least once every 24 hours
E) Applying a facility appropriated wristband to identify a client as a falls risk