A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.

A. Determining if the spouse has medication allergies is unnecessary because the PN should not provide medication to anyone other than the patient. Medication administration policies are strict about who can receive medications and ensuring compliance with these policies is crucial for legal and safety reasons.
B. The PN cannot request medication for individuals who are not patients under their care, so this action does not follow hospital procedures. Medications must be administered through proper channels to ensure they are given safely and legally.
C. Giving medication from the nurse’s personal supply is a violation of hospital policy and professional ethics. All medications must be obtained through approved sources and administered according to prescribed orders for safety and legal reasons.
D. Explaining that medication can only be provided to clients ensures adherence to hospital policies and legal regulations. This action maintains professional boundaries and ensures that only those who are officially under care receive medication.

A. Bacterial conjunctivitis is not a reportable infectious disease according to the CDC. While it is a common condition, it does not fall under the mandatory reporting requirements for public health.
B. Diphtheria is a reportable disease because it is a severe bacterial infection that can lead to outbreaks and severe health consequences. Reporting helps track and control the spread of this potentially life-threatening disease.
C. Pediculosis (head lice) is not a reportable disease by the CDC. It is a common parasitic infestation but does not require mandatory reporting for public health surveillance.
D. Anthrax is a reportable disease due to its potential for severe illness and its use as a bioterrorism agent. Reporting anthrax is crucial for monitoring and managing outbreaks and potential public health threats.
E. Tuberculosis is a reportable disease because it is a serious infectious disease that can spread in communities and requires public health measures to manage and prevent outbreaks.

A. Acknowledging the client's anger and offering to listen validates their feelings and provides an opportunity for the client to express their emotions. This approach can help de-escalate the situation and address the underlying frustrations related to their condition.
B. Playing soft music might be soothing but does not directly address the client's expressed anger or the immediate situation. It is not as effective as acknowledging and listening to the client's concerns.
C. Initiating deep breathing exercises might be helpful but is less effective than directly acknowledging the client's anger and providing a space for them to talk about their feelings.
D. Offering to return later may avoid the immediate conflict but does not address the client’s current emotional state or provide support. It is better to engage with the client in the moment to manage their anger and offer support.

A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.

A. The submandibular lymph nodes are located beneath the lower jaw, in the area where the jawbone meets the neck. This is the correct location to palpate for enlargement of these lymph nodes.
B. The temporal bone is located on the side of the head, not relevant to the location of the submandibular lymph nodes. Palpation for these nodes occurs beneath the lower jaw, not near the temporal bone.
C. Lateral to the trachea refers to the location of other lymph nodes such as the anterior cervical or supraclavicular nodes, not the submandibular nodes. Submandibular nodes are specifically beneath the jaw.
D. Above the upper jaw does not correspond to the location of the submandibular lymph nodes. These nodes are palpated beneath the lower jaw, making this option incorrect.

A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.

1. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.

2. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.

3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.

4. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.

5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently.

A. Irrigating the infected area with a medicated solution is not appropriate for nystatin suspension, which should be applied directly to the infected area. Additionally, sterile gloves are not required for this procedure.
B. Drawing up the medication in a needle-less syringe for the infant to suck is not an effective method for nystatin administration. The medication must be applied directly to the infected area to be effective.
C. Using a gloved finger to rub the suspension over the infected area is the correct method for applying nystatin. This direct application ensures that the medication comes into contact with the infection and is most effective for treating oral candida.
D. Measuring the medication into the infant’s bottle does not ensure that the nystatin is applied to the infected area and may result in the medication being swallowed rather than effectively treating the candida infection.

A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.