Correct Answer: B

Rationale: The correct action for the nurse to take is to notify the healthcare provider. In this situation, involving the healthcare provider ensures appropriate review and adherence to legal and ethical standards based on the living will and durable power of attorney. Referring to the risk manager may not be directly related to the immediate decision-making process regarding the ventilator. Discontinuing the ventilator without proper authorization from the healthcare provider could lead to legal and ethical implications. Reviewing the medical record alone may not provide guidance on how to proceed with the specific instructions from the living will and durable power of attorney.

Correct Answer: C

Rationale: When replacing a client's surgical dressing, the nurse should use sterile gloves to remove the old dressing. Sterile technique is essential to prevent introducing infection to the wound.
Choice A is incorrect because clean gloves are not sufficient; sterile gloves are necessary to maintain asepsis.
Choice B, washing hands, is an important step before and after the procedure to maintain hand hygiene, but sterile gloves are required during the dressing change.
Choice D is incorrect because a new dressing should only be applied after the old one has been removed to prevent contamination and ensure proper wound care.

Correct Answer: A

Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice
B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice
C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice
D) is not advisable as it can be irritating to the skin and may impair the healing process.

Correct Answer: A

Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.

Correct Answer: B

Rationale: The correct answer is B because as a witness, the nurse's primary responsibility is to confirm that the signature on the preoperative consent form belongs to the client. The nurse is not confirming the client's understanding of the procedure (
Choice
A), but rather the authenticity of the signature.
Choice C is incorrect because the nurse is not responsible for verifying that the procedure has been explained, but rather confirming the client's signature. Similarly,
Choice D is incorrect because the nurse's role as a witness is not to ensure the client is aware of potential complications, but to verify the signature.