A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?

Choice A reason: Isoniazid is an antitubercular drug that can cause urine to turn dark yellow or brown, not red-orange.

Choice B reason: Metoprolol is a beta-blocker that can cause urine to turn blue-green, not red-orange.

Choice C reason: Rifampin is an antitubercular drug that can cause urine to turn red-orange, as well as other body fluids such as saliva, sweat, and tears.

Choice D reason: Furosemide is a diuretic that can cause urine to become more concentrated and darker in color, but not red-orange.

Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.

Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.

Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.

Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.