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
Which response is an example of false reassurance?
A"You seem worried. Would you like to talk about it?"
B"I can see this is hard for you."
C"Don't worry, everything will be fine."
D"What are you most concerned about?"
2.Nursing fundamentalsHard
Why must medicines for Parkinson's disease, such as levodopa, be given on time?
AThe timing does not matter as long as the full daily total is given
BThe drug becomes poisonous if it is given late
CLate doses cause the patient to fall asleep
DLate doses can cause severe stiffness, falls and swallowing problems
3.Infection control & patient safetyMedium
Two patients with very similar names are on the same unit. What is the best safety measure?
ACall each patient by their first name only
BTransfer one of the two patients to another hospital
CUse the room numbers to tell the patients apart
DFlag the similar names and check two identifiers every time
4.Infection control & patient safetyHard
A nurse teaches an older adult about preventing falls at home. Which statement shows a need for further teaching?
A“I wear shoes with non-slip soles around the house.”
B“I use night lights between my bedroom and the bathroom.”
C“I had grab bars put in next to the toilet.”
D“I keep small rugs in the hall so my feet stay warm.”
5.Prioritization & delegationMedium
A nurse asks a nursing assistant to “assess the patient’s pain and decide if the patient needs more medication”. Which right of delegation is violated?
ARight circumstance
BRight task
CRight person
DRight supervision and evaluation
6.Prioritization & delegationHard
Which patient on a renal unit should the nurse see first?
AA patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
BA patient on peritoneal dialysis whose drained fluid is clear
CA patient asking for advice about a low-phosphate diet
DA patient whose arteriovenous fistula has a strong thrill and bruit
7.Clinical nursingMedium
Within which time window is IV thrombolysis generally given for acute ischaemic stroke?
AAt any time within a week
BWithin 48 hours of the onset of symptoms
CWithin 4.5 hours of symptom onset
DOnly after 24 hours
8.Clinical nursingHard
A patient has a high fever with rigors, jaundice and right upper quadrant pain. Which condition is most likely?
ASimple biliary colic
BGastro-oesophageal reflux disease
CAscending cholangitis
DAcute appendicitis
9.Lab values & electrolytesMedium
Which factor is most likely to raise a patient’s lithium level?
ADrinking more fluid than usual in hot weather
BTaking each dose with a meal instead of before
CEating more salt than usual for several days
DDehydration or a sudden drop in sodium intake
10.Lab values & electrolytesHard
A patient with heavy alcohol use and a poor diet has a hemoglobin of 10.1 g/dL (101 g/L), an MCV of 110 fL and a low red cell folate. Which explanation fits best?
AIron deficiency from slow, chronic bleeding in the gut
BThalassemia trait inherited from one of the parents
CFolate deficiency, made worse by a direct alcohol effect
DAnemia caused by long-standing chronic kidney disease
11.PharmacologyMedium
Which drug is used for torsades de pointes?
AIntravenous adenosine (rapid push)
BOral digoxin
CIntravenous verapamil
DIntravenous magnesium sulfate
12.PharmacologyHard
Which pair of adverse effects is characteristic of long-term amiodarone treatment?
AOtotoxicity and nephrotoxicity
BDry cough and angioedema
CGum overgrowth and excess hair growth
DThyroid dysfunction and pulmonary fibrosis
13.Med-surg: cardiovascular & respiratoryMedium
A patient on nasal cannula oxygen breathes mainly through the mouth. What is the most accurate statement?
AIt has no effect at all in mouth breathers and must be stopped
BThe flow must be increased to 15 L/min to make it work at all
CThe cannula should be placed in the mouth
DIt can still work, because oxygen collects in the nasopharynx
14.Med-surg: cardiovascular & respiratoryHard
A patient with rheumatoid arthritis is due to start an anti-TNF biologic drug. Which screening is essential beforehand?
AA peak flow diary for a month
BAn exercise ECG test on a treadmill
CScreening for latent tuberculosis
DA sweat chloride test
15.Med-surg: neuro, endocrine & renalMedium
A patient's fistula starts to bleed at home after the needles were removed. What should they do first?
AWait for the next dialysis session
BPress firmly on the site with clean gauze
CRaise the arm and let it bleed freely
DApply a tight tourniquet above the fistula
16.Med-surg: neuro, endocrine & renalHard
A drowsy patient's glucose meter shows "HI". What should the nurse do?
ATreat it as very high, check ketones and escalate
BGive glucose gel in case the reading is wrong
CAssume the meter is broken and recheck tomorrow
DRecord "normal" in the notes because no number appears
17.Med-surg: GI, perioperative & oncologyMedium
Which early symptoms suggest local anaesthetic systemic toxicity?
AMild itching of the feet the next day
BTingling around the mouth, a metallic taste and tinnitus
CA red rash only at the injection site, with no other symptoms
DIncreased hunger and thirst over several hours, with a dry mouth
18.Med-surg: GI, perioperative & oncologyHard
Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?
AWait a few minutes to see if it passes
BCall for help, give 100% oxygen and use a jaw thrust
CSit the patient up and give a drink of water
DGive an opioid to calm the patient's breathing and reduce anxiety
19.Maternity & obstetric nursingMedium
A woman who has had a caesarean asks when she can drive again. Which answer is most accurate?
AOnly after her stitches are removed by a doctor
BThe same day she is discharged
CNever before 6 months
DWhen she can brake hard without pain
20.Maternity & obstetric nursingHard
A preterm baby is being prepared for discharge. Which statement by the parents shows understanding of kangaroo (skin-to-skin) care?
A"Skin-to-skin is only for full-term babies."
B"Skin-to-skin increases her risk of getting cold."
C"Holding her on my bare chest keeps her warm."
D"She should be fully dressed and wrapped before I hold her."
21.Pediatric nursingMedium
How should a parent respond to a 2-year-old's temper tantrum in a safe place?
AStay calm, keep the child safe and do not give in to the demand
BSmack the child to show that tantrums are not allowed
CShout loudly at the child to make the tantrum stop sooner
DGive the child the sweet he wants so the tantrum stops
22.Pediatric nursingHard
An infant with a large VSD now breathes faster, sweats during feeds and has gained 300 g overnight with puffy eyelids. What does this most likely indicate?
ADehydration due to sweating during feeds
BAn allergic reaction to the new high-energy formula started yesterday
CGood growth thanks to improved feeding
DWorsening heart failure with fluid retention
23.Mental health nursingMedium
What is the key difference between factitious disorder and malingering?
AThere is no real difference between them, and both terms mean exactly the same thing
BIn factitious disorder, the symptoms are not produced on purpose at all
CMalingering is a severe mental disorder, while factitious disorder is not classed as a mental disorder at all
DIn factitious disorder, the aim is to be seen as ill; in malingering, the aim is an external reward
24.Mental health nursingHard
A caller says she is a patient's sister and asks how he is doing. The patient has not given consent to share information. What should the nurse do?
AAsk her to prove she is his sister and then share the details
BGive a full update, because she is a close family member
CNeither confirm nor deny that he is there, and offer to pass on a message
DTell her that he is on the ward but refuse to say anything else about his care or condition
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for an injection gives 9.7134 mL. The rule in this exercise is that volumes of 1 mL or more are rounded to the nearest tenth of a mL. What value x do you record?
9.7134 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 2 mcg/min. Express this dose rate D in mg/h.
2 mcg/min1 h = 60 min1 mg = 1000 mcg
D = mg/h
27.Dosage calculationsMedium
A patient weighs 60 kg. The prescribed dose is 15 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
60 kg15 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
A child weighing 8 kg is prescribed 15 mg/kg per dose of an oral suspension that contains 125 mg in 5 mL. What volume V do you give?
8 kg15 mg/kg125 mg/5 mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 10 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute.
1500 mL10 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 100 mg of a drug in 50 mL and runs at 5 mL/h. How many milligrams per hour D does the patient receive?
100 mg/50 mL5 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 100 units of regular insulin in 250 mL runs at 4 mL/h. How many units per hour D does the patient receive?
100 units/250 mL4 mL/h
D = units/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 7.5 mcg/kg/min for a patient who weighs 82 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL7.5 mcg/kg/min82 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 IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
tea: 200 mLwater: 300 mLsoup: 180 mLIV infusion: 100 mL/h × 12 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 75 mL/h. At 10:00, 250 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL250 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: very limited; moisture: occasionally moist; activity: bedfast; mobility: slightly limited; nutrition: very poor; 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). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: no; ambulatory aid: holds on to furniture; IV therapy or saline lock: yes; gait: weak; mental status: knows own limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 79 mmHg (10.5 kPa). Use the rule that in acute respiratory acidosis HCO₃⁻ rises by 1 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a respiratory acidosis: pH 7.29, PaCO₂ 83 mmHg (11.1 kPa), HCO₃⁻ 39 mmol/L. Use the rules ‘HCO₃⁻ rises 1 mmol/L per 10 mmHg (acute) or 3.5 mmol/L per 10 mmHg (chronic)’ to classify it. Click your answer.
pH 7.29PaCO₂ 83 mmHg (11.1 kPa)HCO₃⁻ 39 mmol/L
1acute
2chronic
3acute on chronic
39.ECG rhythm strip interpretationMedium
Measure the QT interval on this lead II strip, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QT = s
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1sinus rhythm with wide QRS
2third-degree (complete) AV block
3dual-chamber (AV) paced rhythm
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: C · "Don't worry, everything will be fine."
Why this is the answer
False reassurance dismisses the patient's feelings and promises something the nurse cannot know. Acknowledging the worry and exploring it is more helpful.
Answer
C · "Don't worry, everything will be fine."
2.Nursing fundamentals
Answer: D · Late doses can cause severe stiffness, falls and swallowing problems
Why this is the answer
Levodopa wears off quickly, and delays can cause rigidity, falls, swallowing difficulty and aspiration. It is a time-critical medicine in hospital.
Answer
D · Late doses can cause severe stiffness, falls and swallowing problems
3.Infection control & patient safety
Answer: D · Flag the similar names and check two identifiers every time
Why this is the answer
Name-alert systems, such as stickers or flags, warn staff, and strict checking of two identifiers prevents mix-ups. Room numbers and first names are not reliable.
Answer
D · Flag the similar names and check two identifiers every time
4.Infection control & patient safety
Answer: D · “I keep small rugs in the hall so my feet stay warm.”
Why this is the answer
Loose rugs are a common cause of trips and falls and should be removed or secured. Night lights, grab bars and non-slip footwear all reduce fall risk.
Answer
D · “I keep small rugs in the hall so my feet stay warm.”
5.Prioritization & delegation
Answer: B · Right task
Why this is the answer
Assessing a patient and deciding on treatment need nursing judgement, so the task itself cannot be delegated to assistive personnel. An assistant can report what the patient says, but the RN assesses and decides.
Answer
B · Right task
6.Prioritization & delegation
Answer: A · A patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
Why this is the answer
A missed dialysis session lets potassium build up. Muscle weakness and an irregular pulse suggest hyperkalemia, which can cause fatal arrhythmias, so the nurse assesses at once, arranges cardiac monitoring and escalates. A thrill and bruit and clear effluent are expected findings, and diet advice can wait.
Answer
A · A patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
7.Clinical nursing
Answer: C · Within 4.5 hours of symptom onset
Why this is the answer
Thrombolysis with alteplase is generally given within 4.5 hours of onset after a scan excludes haemorrhage. Knowing when the patient was last seen well is therefore essential.
Answer
C · Within 4.5 hours of symptom onset
8.Clinical nursing
Answer: C · Ascending cholangitis
Why this is the answer
Fever, jaundice and right upper quadrant pain (Charcot's triad) suggest infection of an obstructed bile duct. It can rapidly cause sepsis and needs antibiotics and biliary drainage.
Answer
C · Ascending cholangitis
9.Lab values & electrolytes
Answer: D · Dehydration or a sudden drop in sodium intake
Why this is the answer
When the body is short of sodium or water, the kidneys keep more sodium and lithium with it, so the level rises. NSAIDs, thiazide diuretics and ACE inhibitors can also raise lithium levels.
Answer
D · Dehydration or a sudden drop in sodium intake
10.Lab values & electrolytes
Answer: C · Folate deficiency, made worse by a direct alcohol effect
Why this is the answer
Poor diet and alcohol reduce folate intake and absorption, causing macrocytic anemia, and alcohol itself also raises the MCV. Iron deficiency and thalassemia cause small cells. Folate is replaced after B12 deficiency is excluded, and thiamine is also commonly given.Checked against:Folate-deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2026)
Answer
C · Folate deficiency, made worse by a direct alcohol effect
11.Pharmacology
Answer: D · Intravenous magnesium sulfate
Why this is the answer
IV magnesium is first-line for torsades de pointes, even when serum magnesium is normal. QT-prolonging drugs are stopped and potassium is corrected.
Answer
D · Intravenous magnesium sulfate
12.Pharmacology
Answer: D · Thyroid dysfunction and pulmonary fibrosis
Why this is the answer
Amiodarone is iodine-rich and accumulates in tissues, causing hypo- or hyperthyroidism, pulmonary fibrosis, liver injury, photosensitivity and corneal deposits. The other pairs fit aminoglycosides, phenytoin and ACE inhibitors.
Answer
D · Thyroid dysfunction and pulmonary fibrosis
13.Med-surg: cardiovascular & respiratory
Answer: D · It can still work, because oxygen collects in the nasopharynx
Why this is the answer
Studies show that mouth breathing still draws in oxygen from the nasopharynx, so nasal cannulae can work. The effect is judged by the SpO₂, and the device is changed if targets are not reached. Cannulae are never placed in the mouth.
Answer
D · It can still work, because oxygen collects in the nasopharynx
14.Med-surg: cardiovascular & respiratory
Answer: C · Screening for latent tuberculosis
Why this is the answer
TNF-alpha is essential for containing TB in granulomas. Anti-TNF drugs can reactivate latent TB, sometimes as severe disseminated disease. Patients are screened (history, chest X-ray, IGRA) and treated for latent TB before starting.
Answer
C · Screening for latent tuberculosis
15.Med-surg: neuro, endocrine & renal
Answer: B · Press firmly on the site with clean gauze
Why this is the answer
Firm, direct pressure with clean gauze or a dressing is applied to the site. A tourniquet could clot the fistula. If bleeding does not stop, the patient calls emergency services, because fistula bleeding can be heavy.
Answer
B · Press firmly on the site with clean gauze
16.Med-surg: neuro, endocrine & renal
Answer: A · Treat it as very high, check ketones and escalate
Why this is the answer
"HI" means the glucose is above the meter's upper range. In a drowsy patient this may be DKA or HHS. A laboratory glucose, ketones, observations and urgent medical review are needed.
Answer
A · Treat it as very high, check ketones and escalate
17.Med-surg: GI, perioperative & oncology
Answer: B · Tingling around the mouth, a metallic taste and tinnitus
Why this is the answer
High blood levels of local anaesthetic first cause CNS symptoms such as perioral tingling, metallic taste, tinnitus, light-headedness and confusion, then seizures and arrhythmias. The injection is stopped and help is called at once.
Answer
B · Tingling around the mouth, a metallic taste and tinnitus
18.Med-surg: GI, perioperative & oncology
Answer: B · Call for help, give 100% oxygen and use a jaw thrust
Why this is the answer
Stridor after extubation suggests laryngospasm or another upper airway obstruction. The nurse calls for help, applies high-flow oxygen and airway manoeuvres, and the anaesthetist may give drugs or reintubate.
Answer
B · Call for help, give 100% oxygen and use a jaw thrust
19.Maternity & obstetric nursing
Answer: D · When she can brake hard without pain
Why this is the answer
There is no fixed time. She can drive when she can brake suddenly, look over her shoulder and wear a seat belt comfortably. Many women need about 4 to 6 weeks, and insurance rules may apply.
Answer
D · When she can brake hard without pain
20.Maternity & obstetric nursing
Answer: C · "Holding her on my bare chest keeps her warm."
Why this is the answer
Kangaroo care places the baby in a nappy against the parent's bare chest. It stabilises temperature, heart rate and breathing, supports breastfeeding and bonding, and is beneficial for preterm babies.
Answer
C · "Holding her on my bare chest keeps her warm."
21.Pediatric nursing
Answer: A · Stay calm, keep the child safe and do not give in to the demand
Why this is the answer
Tantrums are normal as toddlers seek autonomy but cannot yet manage frustration. Staying calm, keeping the child safe, ignoring the outburst and giving attention for calm behaviour work best; giving in reinforces tantrums.
Answer
A · Stay calm, keep the child safe and do not give in to the demand
22.Pediatric nursing
Answer: D · Worsening heart failure with fluid retention
Why this is the answer
A sudden overnight weight gain with periorbital oedema, tachypnoea and sweating suggests fluid retention from worsening heart failure. Daily weights on the same scale are a key way to monitor fluid status in these infants.
Answer
D · Worsening heart failure with fluid retention
23.Mental health nursing
Answer: D · In factitious disorder, the aim is to be seen as ill; in malingering, the aim is an external reward
Why this is the answer
In both, symptoms are produced or exaggerated on purpose. In factitious disorder the motivation is internal, the sick role; in malingering it is external, such as money, drugs or avoiding duties.
Answer
D · In factitious disorder, the aim is to be seen as ill; in malingering, the aim is an external reward
24.Mental health nursing
Answer: C · Neither confirm nor deny that he is there, and offer to pass on a message
Why this is the answer
Without the patient's consent, the nurse should not disclose that a person is receiving mental health care. Offering to pass on a message respects confidentiality while allowing the patient to decide.
Answer
C · Neither confirm nor deny that he is there, and offer to pass on a message
25.Nursing math & unit conversions
Answer: x = 9.7 mL
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
9.7134 → 7
Only the next digit decides
9.7134 → 1
1 is 4 or less, so 7 stays.
The digits after it (34) are ignored: round once, never step by step.
Round
x = 9.7 mL
Answer
x = 9.7 mL
26.Nursing math & unit conversions
Answer: D = 0.12 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 = 2 mcg/min × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 2·60/1000 = 0.12 mg/h
Answer
D = 0.12 mg/h
27.Dosage calculations
Answer: D = 450 mg
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.
Total per day
15·60 = 900 mg
Per dose
D = 900/2 = 450 mg
Answer
D = 450 mg
28.Dosage calculations
Answer: V = 4.8 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
15·8 = 120 mg
Volume
V = (120/125)·5 = 4.8 mL
Answer
V = 4.8 mL
29.IV infusion rates
Answer: R = 25 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
10·60 = 600 min
Drip rate
R = 1500·10/600 = 25 gtt/min
Answer
R = 25 gtt/min
30.IV infusion rates
Answer: D = 10 mg/h
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.
Concentration
100/50 = 2 mg/mL
Dose rate
D = 2·5 = 10 mg/h
Answer
D = 10 mg/h
31.Pediatric & critical-care dosing
Answer: D = 1.6 units/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.
Concentration
100/250 = 0.4 units/mL
Units per hour
D = 4·0.4 = 1.6 units/h
Answer
D = 1.6 units/h
32.Pediatric & critical-care dosing
Answer: R = 36.9 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
250 mg = 250 000 mcg
250 000/250 = 1000 mcg/mL
Dose per minute and per hour
7.5·82 = 615 mcg/min
615·60 = 36900 mcg/h
Pump rate
R = 36900/1000 = 36.9 mL/h
Answer
R = 36.9 mL/h
33.IV fluids & fluid balance
Answer: I = 1980 mL
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.
Add the intake
oral: 200 + 300 + 180 = 680 mL
IV infusion: 100·12 = 1200 mL
IV antibiotic: 1·100 = 100 mL
I = 1980 mL
Answer
I = 1980 mL
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
500 − 250 = 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 13:20.
35.Clinical assessment scores
Answer: B = 12
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: very limited → 2
moisture: occasionally moist → 3
activity: bedfast → 1
mobility: slightly limited → 3
nutrition: very poor → 1
friction and shear: potential problem → 2
Add
Braden total = 2 + 3 + 1 + 3 + 1 + 2 = 12
Answer
B = 12
36.Clinical assessment scores
Answer: high risk
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: no → 0
ambulatory aid: holds on to furniture → 30
IV therapy or saline lock: yes → 20
gait: weak → 10
mental status: knows own limits → 0
Add
Morse total = 25 + 0 + 30 + 20 + 10 + 0 = 85
Risk level
85 → high risk
Answer
high risk
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 27.9 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.
Change in PaCO₂
|79 − 40| = 39 mmHg → 3.9 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·3.9 = 27.9 mmol/L
Answer
HCO₃⁻ = 27.9 mmol/L
38.Arterial blood gas interpretation
Answer: chronic
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.
Expected HCO₃⁻
acute: 24 + 1·4.3 = 28.3 mmol/L
chronic: 24 + 3.5·4.3 = 39.05 mmol/L
Compare
measured: 39 mmol/L → chronic
Answer
chronic
39.ECG rhythm strip interpretation
Answer: QT = 0.42 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
10.5 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 10.5 × 0.04 s = 0.42 s
Answer
QT = 0.42 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 1.08 s).
40.ECG rhythm strip interpretation
Answer: dual-chamber (AV) paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 25 small boxes, 1500 ÷ 25 ≈ 60 per minute.
2. Rhythm: regular, every R–R is 1.00 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.20 s after the first one (the programmed AV delay).
5. QRS: 0.16 s, wide, right after the second spike (ventricular pacing).
Interpretation
dual-chamber (AV) paced rhythm
Answer
dual-chamber (AV) paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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