Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
When should discharge planning begin?
AOnly after the doctor agrees to discharge
BOn admission, or as early as possible
CAfter the patient has gone home
DOn the morning of discharge
2.Nursing fundamentalsHard
A stable patient is woken every hour for observations and is becoming tired and confused. What is the best nursing action?
AAsk the doctor for a sedative to help the patient sleep
BKeep the same plan, as observations matter more than sleep for patients
CAsk the team whether the observations can safely be done less often
DStop all observations so the patient can sleep
3.Infection control & patient safetyMedium
While a sterile field is being prepared, the nurse turns away from it to answer a question. What is correct?
AOnly the items nearest the nurse need to be replaced
BThe field can be used if it is covered afterwards
CThe field is considered contaminated and must be set up again
DThe field is still sterile because nobody touched it in the meantime
4.Infection control & patient safetyHard
Victims of a chemical spill arrive at the emergency department with liquid on their skin and clothing. What is the priority before they enter the building?
ADecontaminate them outside, with staff wearing appropriate PPE
BGive them hospital gowns and seat them in triage
CTake a full history in the waiting room
DTake them straight into the resuscitation room so treatment is not delayed
5.Prioritization & delegationMedium
A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?
AEncourage a large meal to settle the stomach
BWait until tomorrow to see if the vomiting settles
CStop all insulin until the patient is able to eat normally again
DCheck the blood glucose and ketones and contact the provider
6.Prioritization & delegationHard
A patient has a new spinal cord injury at C4. Which assessment is the priority?
ASkin over the sacrum and heels
BBowel sounds in all four abdominal quadrants
CBreathing effort and ability to cough
DAbility to feed themselves
7.Clinical nursingMedium
An older patient is at high risk of falls on the ward. Which nursing action is most appropriate?
AKeep the call bell and belongings within reach and review medicines that cause drowsiness
BUse bed rails for every patient automatically
CRestrict the patient to bed at all times
DRemove the patient's glasses to prevent breakage
8.Clinical nursingHard
A patient has had diarrhoea for three days and is on a medical ward. What is the most appropriate infection control action?
AMove the patient to a shared bay so single rooms stay available
BWait until the diarrhoea has lasted a week before taking any action
CUse alcohol hand rub only and avoid gloves to save resources
DIsolate promptly, use contact precautions and send a stool sample
9.Lab values & electrolytesMedium
When should a blood specimen tube be labeled?
AAt the bedside, in the patient's presence, using two identifiers
BBefore entering the room, so tubes are ready for the next patients
CIn the laboratory, by the staff who receive the unlabeled sample
DAt the nurses' station, after all samples for the shift are drawn
10.Lab values & electrolytesHard
Four drug levels are reported. Which patient should the nurse assess first?
ALithium 1.8 mEq/L with a new coarse tremor
BPhenytoin 15 mcg/mL with no symptoms
CValproate 75 mcg/mL with no symptoms
DDigoxin 1.0 ng/mL with a pulse of 72/min
11.PharmacologyMedium
A patient with a peanut allergy is taught to use an adrenaline auto-injector. Which statement is correct?
AKeep it at home so it is not lost
BCall emergency services after using it, even if symptoms improve
CThere is no need to see a doctor if the swelling goes down
DUse it only if the antihistamine has not worked after an hour
12.PharmacologyHard
A baby born to a mother on methadone becomes irritable on day 2, with a high-pitched cry, tremors, sneezing and poor feeding. What is the most likely cause?
ANeonatal hypoglycaemia from maternal diabetes
BVitamin K deficiency bleeding
CNormal newborn behaviour
DNeonatal opioid withdrawal syndrome
13.Med-surg: cardiovascular & respiratoryMedium
Why is intravenous furosemide given slowly rather than as a rapid push of a large dose?
ASlow injection makes the urine output larger
BRapid doses cause the potassium level to rise
CRapid doses cause severe constipation
DRapid high doses can damage hearing
14.Med-surg: cardiovascular & respiratoryHard
A patient with infective endocarditis is on IV gentamicin with another antibiotic. Which monitoring is most important?
ABlood glucose only
BDrug levels, renal function and hearing or balance changes
CLiver size by daily palpation and weekly abdominal ultrasound
DPeak flow readings and spirometry before and after each dose
15.Med-surg: neuro, endocrine & renalMedium
During DKA treatment, glucose falls below about 14 mmol/L (around 250 mg/dL) but ketones are still raised. What usually happens?
AAll IV fluids are stopped to avoid fluid overload
BGlucose is added to the fluids; insulin continues
CThe patient eats a meal and IV treatment stops
DThe insulin infusion is stopped straight away
16.Med-surg: neuro, endocrine & renalHard
After a TURP, a patient on bladder irrigation has bladder spasms. The drainage has slowed and contains clots, and the bag holds less than the irrigant given. What should the nurse do first?
ASuspect a clot in the catheter and follow the protocol
BGive an antispasmodic and recheck in four hours
CEncourage the patient to strain to pass the clots
DTurn off the irrigation and leave the catheter alone
17.Med-surg: GI, perioperative & oncologyMedium
Why is a pregnancy test often done before surgery in women who could be pregnant?
AAnaesthesia, drugs and some tests may harm a fetus
BPregnant women cannot sign consent forms
CIt is needed to calculate the anaesthetic drug dose
DPregnancy always makes surgery impossible
18.Med-surg: GI, perioperative & oncologyHard
In week 5 of radiotherapy, the skin in the treatment field is broken, moist and painful. What should the nurse do?
AScrub the area with soap to prevent infection
BApply adhesive tape directly over the area to protect it from clothing
CUse a heat pad to speed healing
DReport it, keep it clean and use a non-adherent dressing
19.Maternity & obstetric nursingMedium
Which measure helps prevent infant abduction from a maternity unit?
ALeaving babies in the nursery overnight
BLetting any visitor carry the baby in the corridor
CPosting the baby's name and room on the door
DChecking staff ID before handing over a baby
20.Maternity & obstetric nursingHard
Ten days after birth, a woman phones to say her bleeding has suddenly become heavy and bright red with clots, with lower abdominal pain and a temperature of 38.2 °C (100.8 °F). Which response is most appropriate?
AAsk her to come in now; retained tissue or infection is possible
BAdvise her to use tampons so the blood loss is easier to measure
CTell her it is probably her first period and needs no action
DReassure her that lochia rubra often returns and review at 6 weeks
21.Pediatric nursingMedium
Which statement about patient-controlled analgesia (PCA) for a child is correct?
AParents should press the button whenever the child is asleep
BAny visitor may press it if the child seems uncomfortable
CThe nurse should press it every 5 minutes, day and night, to keep the pain away
DOnly the child presses the button, unless a protocol says otherwise
22.Pediatric nursingHard
A child with a central venous catheter for chemotherapy develops fever and rigors shortly after the line is flushed. What should the nurse suspect?
AAn allergy to the saline flush
BA catheter-related bloodstream infection
CA normal reaction to the chemotherapy
DA blocked line that needs more forceful flushing
23.Mental health nursingMedium
What is the main difference between disulfiram and naltrexone in alcohol dependence?
ABoth work in exactly the same way, so they are fully interchangeable
BDisulfiram causes an unpleasant reaction to alcohol; naltrexone reduces craving and reward
CNaltrexone is used only for alcohol withdrawal; disulfiram is used only for treating an alcohol overdose
DDisulfiram reduces craving; naltrexone causes vomiting when alcohol is drunk
24.Mental health nursingHard
A patient in a catatonic stupor has not eaten or drunk anything for 24 hours and does not respond to speech. What is the priority nursing concern?
AFluid and nutritional intake, and other physical needs
BEncouraging him to join group therapy
CExploring the meaning of his silence with open questions
DTeaching him about his medicines
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A weight conversion gives 144.4943 kg. The rule in this exercise is that weights are rounded to the nearest tenth of a kilogram. What value x do you record?
144.4943 kg
x = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 30 mcg/min. Express this dose rate D in mg/h.
30 mcg/min1 h = 60 min1 mg = 1000 mcg
D = mg/h
27.Dosage calculationsMedium
A vial contains 1 g of powder. The label says: add 4.2 mL of water for injection to give a total volume of 5 mL. The prescription is 400 mg. What volume V of the reconstituted solution do you give?
1 g+ 4.2 mL → 5 mL400 mg
V = mL
28.Dosage calculationsHard
A child weighing 20 kg is prescribed 5 mg/kg per dose of an oral suspension that contains 250 mg in 5 mL. What volume V do you give?
20 kg5 mg/kg250 mg/5 mL
V = mL
29.IV infusion ratesMedium
Infuse 500 mL over 12 hours with a giving set of 60 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL12 h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 100 mg in 250 mL runs at 30 mL/h. How many micrograms per minute D does the patient receive?
100 mg/250 mL30 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 14 units/kg/h for a patient who weighs 95 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL14 units/kg/h95 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 60 kg has an order for norepinephrine at 8 mcg/min. The bag contains 4 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
4 mg/250 mL8 mcg/min60 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The patient weighs 100 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
100 kg12 hurine: 375 mLurine: 450 mLwound drain: 90 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 75 mL/h. At 13:30, 750 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL750 mL infused75 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: no impairment; moisture: constantly moist; activity: walks frequently; mobility: very limited; nutrition: probably inadequate; friction and shear: potential problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 70 mmHg. A patient’s systolic pressure is 122 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 70 mmHg?
MAP 70 mmHgSBP 122 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 18 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 18 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 144, Cl⁻ 114, HCO₃⁻ 14 mmol/L and albumin 31 g/L. Find the albumin-corrected anion gap AGc = AG + 0.25·(40 − albumin).
This lead II strip shows atrial flutter. Measure the flutter-wave interval and find the atrial rate in beats per minute.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
atrial rate = bpm
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. Measure the P–P interval and find the atrial rate in beats per minute (1500 method, whole number).
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
atrial rate = bpm
3Solutions
1.Nursing fundamentals
Answer: B · On admission, or as early as possible
Why this is the answer
Starting discharge planning early allows time for teaching, equipment, referrals and support at home, reducing delays and readmissions.
Answer
B · On admission, or as early as possible
2.Nursing fundamentals
Answer: C · Ask the team whether the observations can safely be done less often
Why this is the answer
Lack of sleep can contribute to delirium. If the patient's scores are stable, the frequency of observations can be reviewed by the team so care is safe but less disruptive.
Answer
C · Ask the team whether the observations can safely be done less often
3.Infection control & patient safety
Answer: C · The field is considered contaminated and must be set up again
Why this is the answer
A sterile field must be kept in view at all times. If sterility cannot be confirmed, the field is treated as contaminated. The rule is: if in doubt, consider it non-sterile.
Answer
C · The field is considered contaminated and must be set up again
4.Infection control & patient safety
Answer: A · Decontaminate them outside, with staff wearing appropriate PPE
Why this is the answer
Contaminated patients are decontaminated outside the department so the chemical is not brought inside to harm staff and other patients. Staff doing this wear PPE suited to the hazard.
Answer
A · Decontaminate them outside, with staff wearing appropriate PPE
5.Prioritization & delegation
Answer: D · Check the blood glucose and ketones and contact the provider
Why this is the answer
Vomiting in type 1 diabetes can lead quickly to diabetic ketoacidosis. Glucose and ketones are checked and the provider is contacted; insulin is usually not stopped completely during illness.
Answer
D · Check the blood glucose and ketones and contact the provider
6.Prioritization & delegation
Answer: C · Breathing effort and ability to cough
Why this is the answer
Injuries at C3–C5 can affect the phrenic nerve and diaphragm, so breathing may fail. Respiratory function is monitored closely, and the patient may need ventilatory support.
Answer
C · Breathing effort and ability to cough
7.Clinical nursing
Answer: A · Keep the call bell and belongings within reach and review medicines that cause drowsiness
Why this is the answer
Falls prevention includes assessing risk factors, reviewing sedating drugs, providing glasses, footwear and walking aids, keeping essentials in reach and supporting toileting.
Answer
A · Keep the call bell and belongings within reach and review medicines that cause drowsiness
8.Clinical nursing
Answer: D · Isolate promptly, use contact precautions and send a stool sample
Why this is the answer
Unexplained diarrhoea may be infective, for example C. difficile or norovirus. Isolation and testing without delay protect other patients.
Answer
D · Isolate promptly, use contact precautions and send a stool sample
9.Lab values & electrolytes
Answer: A · At the bedside, in the patient's presence, using two identifiers
Why this is the answer
Specimens are labeled immediately after collection, at the bedside, after checking two patient identifiers such as name and date of birth. Pre-labeling or labeling away from the patient can put the wrong patient's name on the sample, which can lead to harmful decisions.
Answer
A · At the bedside, in the patient's presence, using two identifiers
10.Lab values & electrolytes
Answer: A · Lithium 1.8 mEq/L with a new coarse tremor
Why this is the answer
A lithium level of 1.8 mEq/L with a coarse tremor suggests toxicity, which can progress to confusion and seizures. The digoxin, phenytoin and valproate levels are within commonly cited ranges and the patients are stable.
Answer
A · Lithium 1.8 mEq/L with a new coarse tremor
11.Pharmacology
Answer: B · Call emergency services after using it, even if symptoms improve
Why this is the answer
Anaphylaxis can recur after the adrenaline wears off (a biphasic reaction). The person always calls for help after using it, carries two auto-injectors and uses adrenaline early.
Answer
B · Call emergency services after using it, even if symptoms improve
12.Pharmacology
Answer: D · Neonatal opioid withdrawal syndrome
Why this is the answer
After birth the baby no longer receives opioid from the mother and develops withdrawal. Assessment uses a scoring tool, with non-drug care first and opioid treatment if signs are severe.
Answer
D · Neonatal opioid withdrawal syndrome
13.Med-surg: cardiovascular & respiratory
Answer: D · Rapid high doses can damage hearing
Why this is the answer
High plasma levels of loop diuretics can cause tinnitus and hearing loss (ototoxicity), especially with fast injection, renal impairment or other ototoxic drugs such as aminoglycosides. Large IV doses are therefore given slowly.
Answer
D · Rapid high doses can damage hearing
14.Med-surg: cardiovascular & respiratory
Answer: B · Drug levels, renal function and hearing or balance changes
Why this is the answer
Gentamicin is nephrotoxic and ototoxic. Levels are measured to guide dosing, renal function is checked regularly and patients are asked about tinnitus, hearing loss and dizziness. Risk is greater with loop diuretics, older age and longer courses.
Answer
B · Drug levels, renal function and hearing or balance changes
15.Med-surg: neuro, endocrine & renal
Answer: B · Glucose is added to the fluids; insulin continues
Why this is the answer
Insulin is continued until ketoacidosis has resolved. To prevent hypoglycaemia as glucose falls, a glucose infusion (for example 10% glucose in UK protocols, 5% dextrose in others) is added alongside the saline. Stopping the insulin early would let ketones rise again.
Answer
B · Glucose is added to the fluids; insulin continues
16.Med-surg: neuro, endocrine & renal
Answer: A · Suspect a clot in the catheter and follow the protocol
Why this is the answer
Clots blocking the catheter make the bladder distend, causing pain and spasms. The nurse checks for kinks, adjusts the irrigation rate per protocol, performs a bladder washout if trained and escalates if not cleared.
Answer
A · Suspect a clot in the catheter and follow the protocol
17.Med-surg: GI, perioperative & oncology
Answer: A · Anaesthesia, drugs and some tests may harm a fetus
Why this is the answer
Unknown pregnancy can change the decision to operate, the timing, and the choice of drugs and X-rays. Testing is offered with consent, according to local policy.
Answer
A · Anaesthesia, drugs and some tests may harm a fetus
18.Med-surg: GI, perioperative & oncology
Answer: D · Report it, keep it clean and use a non-adherent dressing
Why this is the answer
Moist desquamation is a more severe radiation skin reaction. The radiotherapy team is informed; the area is kept clean and covered with non-adherent dressings, avoiding adhesive on the skin, and analgesia is given. Infection is watched for.
Answer
D · Report it, keep it clean and use a non-adherent dressing
19.Maternity & obstetric nursing
Answer: D · Checking staff ID before handing over a baby
Why this is the answer
Matching ID bands, checking staff identification and teaching parents to hand their baby only to identified staff are key. Information about the baby should not be displayed publicly.
Answer
D · Checking staff ID before handing over a baby
20.Maternity & obstetric nursing
Answer: A · Ask her to come in now; retained tissue or infection is possible
Why this is the answer
Heavy bleeding between 24 hours and 12 weeks after birth is a secondary postpartum haemorrhage. With pain and fever it suggests retained placental tissue or endometritis, which needs same-day assessment and possibly ultrasound, antibiotics or evacuation. Tampons are avoided in the postnatal period.
Answer
A · Ask her to come in now; retained tissue or infection is possible
21.Pediatric nursing
Answer: D · Only the child presses the button, unless a protocol says otherwise
Why this is the answer
PCA is safe because a sedated child stops pressing the button. If others press it ("PCA by proxy") this safety is lost, risking overdose. Nurse- or parent-controlled analgesia is only used under specific protocols with extra monitoring.
Answer
D · Only the child presses the button, unless a protocol says otherwise
22.Pediatric nursing
Answer: B · A catheter-related bloodstream infection
Why this is the answer
Fever and rigors linked to flushing or use of a central line strongly suggest line infection. Blood cultures are taken (often from the line and a peripheral vein) and IV antibiotics are started urgently, especially if the child is neutropenic.
Answer
B · A catheter-related bloodstream infection
23.Mental health nursing
Answer: B · Disulfiram causes an unpleasant reaction to alcohol; naltrexone reduces craving and reward
Why this is the answer
Disulfiram blocks the breakdown of acetaldehyde, so drinking causes flushing, nausea and palpitations. Naltrexone blocks opioid receptors and reduces the pleasurable effect of alcohol.
Answer
B · Disulfiram causes an unpleasant reaction to alcohol; naltrexone reduces craving and reward
24.Mental health nursing
Answer: A · Fluid and nutritional intake, and other physical needs
Why this is the answer
In catatonic stupor, the patient may not eat, drink, move or pass urine normally. Dehydration, malnutrition, pressure injuries and blood clots are real risks, so physical care is the priority while medical treatment is started.
Answer
A · Fluid and nutritional intake, and other physical needs
25.Nursing math & unit conversions
Answer: x = 144.5 kg
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the tenths place
144.4943 → 4
Only the next digit decides
144.4943 → 9
9 is 5 or more, so round 4 up.
The digits after it (43) are ignored: round once, never step by step.
Round
x = 144.5 kg
Answer
x = 144.5 kg
26.Nursing math & unit conversions
Answer: D = 1.8 mg/h
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 30 mcg/min × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 30·60/1000 = 1.8 mg/h
Answer
D = 1.8 mg/h
27.Dosage calculations
Answer: V = 2 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration after mixing
1000 mg/5 mL = 200 mg/mL
Volume
V = 400/200 = 2 mL
Answer
V = 2 mL
28.Dosage calculations
Answer: V = 2 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose from weight
5·20 = 100 mg
Volume
V = (100/250)·5 = 2 mL
Answer
V = 2 mL
29.IV infusion rates
Answer: R = 42 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Time in minutes
12·60 = 720 min
Drip rate
R = 500·60/720 = 41.67 ≈ 42 gtt/min
Answer
R = 42 gtt/min
At the bedside you round to the nearest whole drop: 42 gtt/min.
30.IV infusion rates
Answer: D = 200 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
100000 mcg/250 mL = 400 mcg/mL
Dose per hour
30·400 = 12000 mcg/h
Dose per minute
D = 12000/60 = 200 mcg/min
Answer
D = 200 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 13.3 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
14·95 = 1 330 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1330/100 = 13.3 mL/h
Answer
R = 13.3 mL/h
32.Pediatric & critical-care dosing
Answer: R = 30 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
4 000/250 = 16 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
8·60 = 480 mcg/h
Pump rate
R = 480/16 = 30 mL/h
Answer
R = 30 mL/h
33.IV fluids & fluid balance
Answer: U = 0.69 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
375 + 450 = 825 mL
Per kilogram per hour
U = 825/(100·12) = 0.6875 ≈ 0.69 mL/kg/h
Answer
U = 0.69 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 3.3 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
1000 − 750 = 250 mL
Time
t = 250/75 = 3.333 ≈ 3.3 h
Answer
t = 3.3 h
That is about 3 h 20 min, so the bag runs out at about 16:50.
35.Clinical assessment scores
Answer: B = 15
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: no impairment → 4
moisture: constantly moist → 1
activity: walks frequently → 4
mobility: very limited → 2
nutrition: probably inadequate → 2
friction and shear: potential problem → 2
Add
Braden total = 4 + 1 + 4 + 2 + 2 + 2 = 15
Answer
B = 15
36.Clinical assessment scores
Answer: DBP = 44 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·70 − 122)/2 = 88/2 = 44 mmHg
Answer
DBP = 44 mmHg
37.Arterial blood gas interpretation
Answer: PaCO₂ = 35 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Winter’s formula
PaCO₂ = 1.5·18 + 8 = 35 mmHg
range: 33–37 mmHg
Answer
PaCO₂ = 35 mmHg
38.Arterial blood gas interpretation
Answer: AGc = 18.25 mmol/L
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Anion gap
AG = 144 − (114 + 14) = 16
Correction for albumin
16 + 0.25·(40 − 31) = 18.25 mmol/L
Answer
AGc = 18.25 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: atrial rate = 300 bpm
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 per minute
conduction ratio = 300 ÷ 75 = 4:1
Answer
atrial rate = 300 bpm
40.ECG rhythm strip interpretation
Answer: atrial rate = 83 bpm
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Atrial rate
P–P = 18 small boxes = 0.72 s → 1500 ÷ 18 = 83.33 ≈ 83 per minute
Ventricular rate
R–R = 44 small boxes = 1.76 s → 1500 ÷ 44 = 34.09 ≈ 34 per minute
Answer
atrial rate = 83 bpm
Answer
atrial rate = 83 bpm
Third-degree block with a wide-complex ventricular escape (usually 20–40 per minute).
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