Correct Answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (
Choice
A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (
Choice
C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (
Choice
D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

Correct Answer: B

Rationale: Confirming the patient's allergies before administering medications is crucial for patient safety as it helps prevent adverse reactions. Checking the patient's wristband is important for identification but may not directly impact medication safety. Documenting medications after administration is necessary but does not primarily promote safety during administration. Preparing medications at the medication cart, rather than the nurse's station, is preferred to ensure accuracy and proper medication handling, but it is not directly related to confirming allergies for safety.

Correct Answer: B

Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (
Choice
A) can be important but should come after cleaning the wound. Administering antibiotics (
Choice
C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (
Choice
D) is essential but not the most important initial intervention.

Correct Answer: C

Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms.
Therefore, the perioperative nurse should apply a new mask.
Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable.
Choice B is not the best course of action as the mask should be changed immediately when it becomes moist.
Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.

Correct Answer: B

Rationale: The correct answer is B: Stop the infusion and notify the healthcare provider. Pain and swelling at an IV site can indicate infiltration or infection, which are serious complications. Stopping the infusion helps prevent further harm to the client, and notifying the healthcare provider promptly allows for appropriate assessment and intervention.
Choice A is incorrect because flushing the IV line and continuing the infusion could exacerbate the issue.
Choice C is incorrect as increasing the IV infusion rate is not the appropriate action for pain and swelling at the site.
Choice D is incorrect because applying a warm compress may not address the underlying issue of infiltration or infection; it's crucial to stop the infusion and seek further guidance.