A nurse is planning preoperative teaching for a client who is scheduled for a cholecystectomy. The client does not speak the same language as the nurse and is accompanied by her adolescent daughter. Which of the following actions should the nurse take?

Choice A reason: Notifying staff of the increased fall rate is not the first action that the nurse should take, as it does not address the root cause of the problem or the possible solutions. The nurse should inform the staff of the fall rate after conducting a thorough analysis and developing a plan of action.

Choice B reason: Identifying clients who are at risk for falls is the first action that the nurse should take, as it helps to determine the scope and severity of the problem and the factors that contribute to it. The nurse should use a valid and reliable tool to assess the fall risk of each client and document the findings.

Choice C reason: Reviewing current literature regarding client falls is not the first action that the nurse should take, as it does not provide specific information about the facility's situation or the client's needs. The nurse should review the literature after identifying the clients who are at risk for falls and before implementing a fall prevention plan.

Choice D reason: Implementing a fall prevention plan is not the first action that the nurse should take, as it requires evidence-based interventions and evaluation methods that are tailored to the facility's context and the client's characteristics. The nurse should implement a fall prevention plan after reviewing the current literature and obtaining approval from the stakeholders.

Choice A reason: The client needs to have someone come in to help her bathe at home is not a data that supports a referral for a social worker, as it is a need for home health care or personal care assistance. The nurse should refer the client to a home health agency or a community resource that provides such services.

Choice B reason: The client needs to arrange financial resources to purchase equipment is a data that supports a referral for a social worker, as it is a need for financial assistance or counseling. The nurse should refer the client to a social worker who can help the client access available resources, such as insurance, grants, or loans, to cover the cost of the equipment.

Choice C reason: The client needs to have someone bring oxygen tanks and equipment to her home is not a data that supports a referral for a social worker, as it is a need for oxygen therapy or equipment delivery. The nurse should refer the client to a respiratory therapist or a durable medical equipment company that can provide the oxygen and the equipment.

Choice D reason: The client needs to have range-of-motion exercises to assist with ambulation is not a data that supports a referral for a social worker, as it is a need for physical therapy or rehabilitation. The nurse should refer the client to a physical therapist or a rehabilitation center that can provide the exercises and the guidance.