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. While measuring a patient's blood pressure, which factor influences a patient's blood pressure?

• A. Pulse rate
• B. Pulse pressure
• C. Vascular output
• D. Peripheral vascular resistance

Correct answer: D

Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (Choice A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (Choice B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (Choice C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.

3. Which technique is correct when assessing the radial pulse of a patient?

• A. Palpate for 1 minute if the rhythm is irregular.
• B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
• C. Palpate for 2 full minutes to detect any variation in amplitude.
• D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.

Correct answer: A

Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.

4. After change-of-shift report, which patient should the nurse assess first?

• A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
• B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
• C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
• D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.

5. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?

• A. Belief in and worship of God or gods
• B. Being closely tied to one's ethnic background
• C. Attendance at a specific church or place of worship
• D. A connection with something larger than oneself and belief in transcendence

Correct answer: D

Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.

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