Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.

Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.

Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.

Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.

Choice A rationale: Norming is characterized by the development of group cohesion and establishment of norms, not necessarily high-level problem-solving.

Choice B rationale: Storming is marked by conflict and tension within the group, not optimal problem-solving.

Choice C rationale: Forming is the initial stage where members get to know each other; it does not represent a highly functioning team.

Choice D rationale: Performing is the stage where the group is functioning at its highest level, demonstrating effective problem-solving and productivity.

Choice A rationale: Under-delegation is not related to giving too much responsibility to assistive personnel; it is about appropriate delegation based on the nurse's assessment of the situation.

Choice B rationale: Trust in delegates is essential, and under-delegation is more likely related to a lack of trust or confidence in delegation.

Choice C rationale: Under-delegation can occur due to a nurse's need for perfectionism and control, leading to a reluctance to delegate tasks to others.

Choice D rationale: Nurses often have heavy workloads, and under-delegation may be a result of feeling there is not enough time to delegate effectively.

Choice A rationale: Hypernatremia involves elevated sodium levels, so encouraging potassium-rich foods is not directly related to addressing hypernatremia.

Choice B rationale: Restricting sodium in the diet is appropriate to help manage and reduce hypernatremia. This can prevent further complications of hypernatremia, such as dehydration, confusion, seizures, and coma.

Choice C rationale: This is not an appropriate intervention for hypernatremia, as water intake can help dilute the sodium levels and restore the fluid balance in the body.

Decreasing water intake can worsen the hypernatremia and cause dehydration. Choice D rationale: This is an appropriate intervention for hypernatremia, as high sodium levels can affect the fluid balance and blood pressure in the body. Monitoring

vital signs can help detect any changes or abnormalities that may indicate worsening of the condition or need for further treatment.

Choice E rationale: Monitoring intake and output helps assess fluid balance and response to interventions for hypernatremia.

Choice A rationale: Applying an ice pack after a topical agent is not primarily for decreasing discomfort but rather to achieve a specific therapeutic effect.

Choice B rationale: Applying an ice pack can slow the absorption of the topical drug, allowing for prolonged local action.

Choice C rationale: Enhancing drug excretion is not typically achieved by applying an ice pack.

Choice D rationale: Maximizing drug distribution is not the primary purpose of applying an ice pack after a topical agent.

Choice A rationale: RLQ (Right Lower Quadrant) is the correct abbreviation for the location of the appendix, which is typically found in the right lower quadrant of the abdomen.

Choice B rationale: RUQ (Right Upper Quadrant) is not the location of the appendix.

Choice C rationale: LUQ (Left Upper Quadrant) is not the location of the appendix.

Choice D rationale: LLQ (Left Lower Quadrant) is not the location of the appendix.

Choice A rationale: The sclera by the outer canthus is not the typical site for administering eyedrops bilaterally.

Choice B rationale: Dropping medication onto the center of the cornea is not the recommended technique for administering eyedrops.

Choice C rationale: The sclera by the inner canthus is not the usual site for administering eyedrops bilaterally.

Choice D rationale: The lower conjunctival sac is the appropriate area for administering eyedrops, ensuring proper absorption and distribution.

Choice A rationale: Inhaling slowly to raise the ball to the desired level and attempting to keep the ball raised for several seconds is the correct technique for using an incentive spirometer.

Choice B rationale: Blowing into the mouthpiece with a long slow expiration is not the correct technique for using an incentive spirometer.

Choice C rationale: Beginning breathing with a rapid, forceful inspiration is not the recommended technique for using an incentive spirometer.

Choice D rationale: Exhaling slowly to raise the ball and quickly inhaling is not the correct technique for using an incentive spirometer.

Choice A rationale: Acetaminophen 500 mg PO is subject to the first pass effect as it is absorbed through the gastrointestinal system.

Choice B rationale: Dulcolax suppository is not subject to the first pass effect as it is administered rectally.

Choice C rationale: Aspirin 10 mg PO is subject to the first pass effect as it is absorbed through the gastrointestinal system.

Choice D rationale: Fentanyl 25 mcg/h via transdermal patch avoids the first pass effect as it is absorbed through the skin.

Choice E rationale: Morphine 0.4 mg IV avoids the first pass effect as it is administered intravenously.

Choice A rationale: Maintaining continuous oxygen therapy does not directly address the thinning of respiratory secretions.

Choice B rationale: Maintaining a consistent air temperature in the client's room is not directly related to thinning respiratory secretions.

Choice C rationale: Keeping the client in a supine position as much as possible is not the most helpful action for thinning respiratory secretions.

Choice D rationale: Assisting the client to maintain an adequate fluid intake is the most helpful action in thinning respiratory secretions, promoting hydration and mobilization of secretions.

Choice A rationale: Shared responsibility is a necessary feature of a team, promoting collaboration and achievement of common goals.

Choice B rationale: Mutual independence allows team members to work together while maintaining individual contributions.

Choice C rationale: Working in the same department is not a necessary feature of a team. Teams can be effective regardless of their physical proximity.

Choice D rationale: Common purpose is essential for a team to work cohesively toward shared goals.

Choice A rationale: A serum magnesium level of 1.8 mEq/L is lower than the normal range and can be associated with alcohol withdrawal.

Choice B rationale: Potassium level within the normal range is not specifically indicative of alcohol withdrawal.

Choice C rationale: Calcium level within the normal range is not specifically indicative of alcohol withdrawal.

Choice D rationale: Phosphorus level within the normal range is not specifically indicative of alcohol withdrawal.

Choice A rationale: Promotion of oxygenation by enhancing air circulation around the wound is not the primary treatment for a "yellow" wound.

Choice B rationale: Removal of nonviable tissue followed by a moist wound dressing is the expected treatment for a wound with yellow color, indicating the presence of slough (nonviable tissue).

Choice C rationale: Use of barrier cream and a foam dressing may be indicated for other types of wounds but may not address the specific issue of nonviable tissue in a "yellow" wound.

Choice D rationale: No treatment is necessary is not appropriate for a wound with evidence of nonviable tissue.

Choice A rationale: An inflammatory response, including mild fever and malaise, is common during the inflammatory phase of healing, which occurs in the initial postoperative period.

Choice B rationale: Proliferation is the phase of healing characterized by tissue repair and regeneration, not by fever and malaise.

Choice C rationale: Remodeling is the final phase of healing involving tissue maturation and strengthening, not associated with generalized body responses.

Choice D rationale: Infection is a separate complication and may present with more severe symptoms than mild fever and malaise.

Choice A rationale: The normal stimulus to breathe is an increased carbon dioxide level, which stimulates the respiratory center in the brain.

Choice B rationale: Increased oxygen levels do not serve as the primary stimulus for breathing. The respiratory center is primarily responsive to carbon dioxide levels.

Choice C rationale: Increased carbon dioxide level is the correct stimulus for normal breathing.

Choice D rationale: Decreased oxygen level is not the primary stimulus for normal breathing.

Choice A rationale: Loperamide 2 mg is generally available in liquid form, so crushing is not typically necessary.

Choice B rationale: Diltiazem SR 180 mg (Sustained Release) should not be crushed, as it is formulated for extended release over time.

Choice C rationale: Acetaminophen 325 mg is usually available in liquid form, so crushing may not be necessary.

Choice D rationale: Methyldopa 125 mg is generally available in liquid form, so crushing may not be necessary.

Choice A rationale: Ineffective gas exchange is related to respiratory issues but may not be the priority in this case.

Choice B rationale: Ineffective breathing pattern is the priority problem, as evidenced by shallow respirations and reluctance to perform coughing and deep breathing, which can lead to respiratory complications.

Choice C rationale: Activity intolerance is not the priority problem based on the given data.

Choice D rationale: Decreased cardiac function is not the priority problem based on the given data.

Choice A rationale: Placing the client in reverse Trendelenburg position is not the first priority; protecting the wound is more critical.

Choice B rationale: Administering IV antibiotics STAT is not the first priority in the presence of evisceration.

Choice C rationale: Using sterile gloves to replace the protruding parts is not the first intervention; covering the wound takes precedence.

Choice D rationale: Applying a sterile normal saline dressing is the first priority to cover and protect the exposed abdominal contents.

Choice A rationale: Spreading the skin taut while inserting the needle can minimize discomfort by reducing the sensation of the needle puncturing the skin.

Choice B rationale: Applying heat to the area before the injection is not a common practice and may not significantly reduce discomfort during the injection.

Choice C rationale: Holding the barrel of the syringe still while injecting the medication is important for accuracy but does not specifically address minimizing discomfort.

Choice D rationale: Testing for blood return before injecting the medication is a technique used with intramuscular but it does not minimize pain during injection.

Choice A rationale: Carbon dioxide level is not a direct indicator of the blood's ability to transport oxygen.

Choice B rationale: Surfactant level is not a direct indicator of the blood's ability to transport oxygen; surfactant is related to lung function.

Choice C rationale: Bicarbonate ion level is more related to acid-base balance and not a direct indicator of the blood's ability to transport oxygen.

Choice D rationale: Hemoglobin level provides the most information about the blood's ability to transport oxygen, as hemoglobin carries oxygen to tissues.

Choice A rationale: R/O (rule out) is not appropriate for documenting the client's current presentation.

Choice B rationale: S/P (status post) is not appropriate for describing the client's current respiratory distress.

Choice C rationale: SOB (shortness of breath) is the correct abbreviation to document the client's difficulty in breathing.

Choice D rationale: DOB (date of birth) is not relevant to the client's respiratory distress.

Choice A rationale: Medication concentration being half of what it was when administered is not the definition of the trough level.

Choice B rationale: Medication becoming toxic is not the definition of the trough level. Choice C rationale: Blood serum drug concentration being lowest is the correct definition of the trough level.

Choice D rationale: Highest effective drug concentration in the blood being reached is not the definition of the trough level.

Choice A rationale: S/P (status post) is not the correct abbreviation for the administration route of a glycerin suppository.

Choice B rationale: RS is not the correct abbreviation for the administration route of a glycerin suppository.

Choice C rationale: R is not the correct abbreviation for the administration route of a glycerin suppository.

Choice D rationale: PR (per rectum) is the correct abbreviation for the administration route of a glycerin suppository.

Choice A rationale: Instructing the client to shift their weight at least every 15 minutes helps prevent pressure injuries.

Choice B rationale: Keeping the head of the bed raised at 45 degrees at all times is not a typical practice for preventing pressure injuries.

Choice C rationale: Massaging over bony prominences every hour while awake may not be recommended, as this can cause friction and shear, contributing to skin breakdown. Choice D rationale: Applying moisture barrier cream to perineal skin helps protect against skin breakdown from urinary incontinence.

Choice E rationale: Consulting with the wound care nurse about the use of a specialty mattress can provide additional support and help prevent pressure injuries.

Choice A rationale: Diluting potassium elixir in juice is not a priority intervention for a critically elevated potassium level. Immediate actions are needed.

Choice B rationale: Monitoring intake and output is important, but it is not the highest priority when the potassium level is critically elevated.

Choice C rationale: Assessing the client for muscle weakness and flaccid paralysis is a high priority because hyperkalemia can lead to serious cardiac and neuromuscular complications.

Choice D rationale: Encouraging intake of orange juice or a banana may be appropriate for managing mild hypokalemia, but it is not the priority for a client with critically elevated potassium.

Choice E rationale: Obtaining a physician's order for cardiac monitoring is crucial, as hyperkalemia can lead to life-threatening cardiac dysrhythmias.