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. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

• A. A little, a moderate amount, or all of the meal
• B. 50 cc, 100 cc, or 500 cc of the meal
• C. 25%, 50%, or 100% of the meal
• D. Either A or C

Correct answer: C

Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

3. You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?

• A. You will place the stethoscope over the heart and listen for any irregular beats.
• B. You will place the stethoscope over the heart and count the beats per minute.
• C. You will place your fingertip over the patient's wrist and feel for any irregular beats.
• D. You will place your fingertip over the patient's wrist and count the beats per minute.

Correct answer: B

Rationale: To take an apical pulse accurately, you should place the stethoscope over the heart and count the number of beats per minute. This method provides a precise assessment of the heart rate. While listening for irregular beats is essential for assessing the heart's rhythm, the primary objective of taking an apical pulse is to determine the heart rate. Choices C and D are incorrect because the apical pulse is not taken at the wrist; instead, it is obtained by auscultating at the apex of the heart, usually at the point where the fifth intercostal space meets the midclavicular line.

4. Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.

• A. head of the bed on the patient's right side
• B. head of the bed on the patient's left side
• C. bottom of the bed on the patient's right side
• D. bottom of the bed on the patient's left side

Correct answer: B

Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.

5. Where is the Loop of Henle located in the body?

• A. Liver
• B. Kidney
• C. Heart
• D. Ear

Correct answer: B

Rationale: The Loop of Henle is a crucial structure found in the kidneys. It plays a vital role in the concentration of urine by creating a concentration gradient in the renal medulla. Choices A, C, and D are incorrect because the Loop of Henle is not located in the liver, heart, or ear. Understanding the anatomical location of the Loop of Henle is essential in comprehending renal physiology and the mechanism of action of diuretic medications.

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