Nursing Elites

1. Which of the following may represent an upper airway obstruction?

• A. Retractions
• B. Elongated expiratory phase
• C. Stridor
• D. Expiratory wheezing

Correct answer: C

Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).

2. During a general survey of a patient, which finding is considered normal?

• A. Body mass index (BMI) of 20.
• B. When standing, the patient's base is narrow.
• C. The patient appears older than their stated age.
• D. Arm span (fingertip to fingertip) is greater than the height.

Correct answer: A

Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome. Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range. Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.

3. In the Gram Stain procedure, which component acts as the mordant?

• A. Crystal violet
• B. Methyl alcohol
• C. Iodine
• D. Safranin

Correct answer: C

Rationale: In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.

4. Patients exhibiting signs of cyanosis will:

• A. show signs of hyperoxia.
• B. have increased O2 saturation.
• C. have blood levels of CO2 higher than O2 levels.
• D. None of the above.

Correct answer: C

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.

5. Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?

• A. Grimacing
• B. Anxiety
• C. Oxygenation saturation 93%
• D. Output 500 mL in 8 hours

Correct answer: B

Rationale: The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.

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