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 combination of signs suggests a wound infection?
AMild itching as the edges close
BA dry scab with no pain
CPink granulation tissue, mild serous fluid and a shrinking wound
DIncreasing redness, warmth, swelling, pain and pus
2.Nursing fundamentalsHard
What is the effect of deflating the blood pressure cuff too quickly?
AOnly the pulse rate is affected, not the blood pressure
BBoth the systolic and diastolic will be read too high
CThe reading becomes more accurate because it is faster
DThe systolic may be read too low and the diastolic too high
3.Infection control & patient safetyMedium
Why are independent double checks used for some medicines, such as insulin and heparin infusions?
AA second person checking separately catches missed errors
BTo share responsibility between two nurses if an error happens
CBecause these drugs are very expensive to waste
DTo make the preparation process faster
4.Infection control & patient safetyHard
A nurse has a needlestick from a patient known to have hepatitis C. Which statement about management is correct?
AHepatitis C immune globulin is given within 24 hours, followed by a booster dose
BThere is no preventive drug, so baseline and follow-up testing are done to detect infection early
CNo follow-up is needed because hepatitis C does not spread by needles
DThe hepatitis C vaccine series is started at once, with a booster dose six months later
5.Prioritization & delegationMedium
A patient asks the nursing assistant about the side effects of a new medication. What should the assistant do?
AExplain the side effects listed in the drug’s patient leaflet
BLook the drug up online and read out what it says
CSay the nurse will come to answer, and tell the nurse
DReassure the patient that side effects are rare
6.Prioritization & delegationHard
After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?
ANeurogenic shock
BHypovolemic shock
CCardiac tamponade
DSeptic shock
7.Clinical nursingMedium
Which adverse effects should be monitored for in a patient receiving IV gentamicin?
AConstipation and urinary retention
BKidney damage and hearing loss
CHair loss and weight gain
DHyperglycaemia and tremor
8.Clinical nursingHard
A patient's hypoglycaemia was caused by a sulfonylurea such as gliclazide or glipizide. Why might they need monitoring for longer than usual?
AThe drug makes glucose tablets and drinks ineffective
BSulfonylureas act for a long time, so hypoglycaemia can recur
CThe drug causes rebound hyperglycaemia later the same day
DSulfonylureas only work at night
9.Lab values & electrolytesMedium
A patient with diabetes also takes propranolol. Why is regular glucose monitoring especially important?
AThe drug causes very high glucose in all patients
BThe drug stops the meter from reading correctly
CThe drug blocks the insulin injection site
DThe drug can mask warning signs of hypoglycemia
10.Lab values & electrolytesHard
A patient with heart failure takes lisinopril, spironolactone and a potassium supplement. Today the potassium is 6.0 mEq/L. What is the most likely explanation?
ASeveral medicines that raise potassium are being taken together
BPotassium supplements have no effect on the serum level
CSpironolactone causes potassium loss
DLisinopril lowers potassium
11.PharmacologyMedium
A child is starting methylphenidate for ADHD. Which advice is appropriate?
AExpect weight gain as the main side effect
BGive the last dose at bedtime to help the child sleep
CGive doses early in the day and monitor appetite and growth
DGive the drug only at weekends
12.PharmacologyHard
A drug has a volume of distribution of 40 L and complete bioavailability. Which loading dose gives a target plasma concentration of 2 mg/L?
A20 mg
B80 mg
C42 mg
D160 mg
13.Med-surg: cardiovascular & respiratoryMedium
After an acute coronary syndrome, a patient with a normal cholesterol level is prescribed a high-intensity statin. Why?
AStatins are given after an ACS mainly to lower the blood pressure
BStatins work as painkillers for chest pain
CStatins reduce further events whatever the starting cholesterol
DStatins are needed only if the cholesterol level is very high
14.Med-surg: cardiovascular & respiratoryHard
A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?
AAn expected effect of the antibiotic
BA catheter-related deep vein thrombosis
CA local skin allergy to the dressing
DLymphoedema from lying in bed
15.Med-surg: neuro, endocrine & renalMedium
A conscious patient with a glucose of 3.1 mmol/L (56 mg/dL) can swallow safely. Which is the best first treatment?
AA dose of rapid-acting insulin with a sandwich
BGlucose tablets or a small glass of fruit juice
CA chocolate bar and a cup of tea with milk
DA glass of milk and two plain biscuits
16.Med-surg: neuro, endocrine & renalHard
A patient in thyroid storm has a temperature of 40 °C (104 °F). Which measure for the fever is usually avoided?
ACooling blankets
BFanning with cool air
CAspirin
DParacetamol (acetaminophen)
17.Med-surg: GI, perioperative & oncologyMedium
Why is a gastrostomy tube with an internal bumper usually advanced and rotated regularly once the tract has healed?
ATo make the tube longer as the patient grows or gains weight
BTo check that the patient is still hungry
CTo remove any feed left in the stomach
DTo stop the inner bumper becoming buried in the stomach wall
18.Med-surg: GI, perioperative & oncologyHard
A patient on modified-release morphine for cancer pain has needed four breakthrough doses every day for several days. What should the nurse do?
AReport it, as the regular background dose may need review
BGive all breakthrough doses at the same time
CTell the patient to put up with the pain between doses
DStop the breakthrough doses to reduce opioid use
19.Maternity & obstetric nursingMedium
Which newborn finding is commonly associated with Down syndrome?
ALong nails and peeling skin
BA single palmar crease and low tone
CAbundant vernix and lanugo
DA high-pitched cry and tremors
20.Maternity & obstetric nursingHard
Six hours after birth, a woman has not passed urine. The fundus is boggy and displaced to the right, and bleeding has increased. Why is this a priority?
AIt shows that the epidural is still working well
BA full bladder prevents the uterus from contracting and increases bleeding
CA full bladder is a sign of normal recovery
DUrine retention only matters after a caesarean birth, not after a vaginal one
21.Pediatric nursingMedium
Which growth chart finding in a 10-month-old most needs further evaluation?
ALength on the 50th percentile and weight on the 40th percentile
BHead circumference that follows the 75th percentile curve
CWeight that has stayed on the 10th percentile since birth
DWeight that has fallen across two major percentile lines since the last visits
22.Pediatric nursingHard
Which statement by the parent of a child with peanut allergy shows a need for further teaching?
A"I'll call an ambulance every time I use the auto-injector, even if she seems to recover quickly."
B"If she has a bad reaction, I'll give an antihistamine and wait an hour before using the auto-injector."
C"I'll check the use-by date on her auto-injectors regularly and replace them before they expire."
D"I'll read food labels for peanuts every time I shop."
23.Mental health nursingMedium
A patient who has just been admitted says, "I don't want to talk to anyone." What is the best initial nursing approach?
AAsk a series of direct questions until he answers
BSpend short, regular periods with the patient without forcing conversation
CTell the patient that talking is required to be discharged
DLeave the patient alone until he asks to talk
24.Mental health nursingHard
A 50-year-old man has believed for a year that his wife is unfaithful. He works normally, his speech is organised and he has no hallucinations. Which diagnosis is most likely?
ASchizophrenia
BBipolar I disorder
CSchizophreniform disorder
DDelusional disorder
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 7 lb 1 oz. Using 1 lb = 16 oz and 1 kg = 2.2 lb, find the weight m in kilograms. Round to two decimal places.
7 lb 1 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 17:15 and finishes at 02:15 the next morning (24-hour clock). How many hours t did it run? Give the answer in hours as a decimal, rounded to two decimal places.
17:1502:15
t = h
27.Dosage calculationsMedium
A child weighing 25 kg is prescribed 10 mg/kg of a drug. The stock solution contains 50 mg/mL. Draw up the dose: what volume V do you give?
25 kg10 mg/kg50 mg/mL
V = mL
28.Dosage calculationsHard
You must prepare 500 mL of a 2.5% (w/v) solution from a 10% (w/v) stock solution. What volume of stock V₁ do you need?
C₁ = 10%C₂ = 2.5%V₂ = 500 mL
V₁ = mL
29.IV infusion ratesMedium
An infusion is ordered at 120 mL/h, but no pump is available. It runs by gravity through a giving set of 10 gtt/mL. Find the drip rate R in drops per minute.
120 mL/h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 100 mg of a drug in 500 mL and runs at 15 mL/h. How many milligrams per hour D does the patient receive?
100 mg/500 mL15 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 dopamine 800 mg in 500 mL. The order is 2 mcg/kg/min for a patient who weighs 94 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL2 mcg/kg/min94 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 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
soup: 150 mLtea: 240 mLwater: 350 mLIV infusion: 60 mL/h × 8 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 19:30 at 150 mL/h. After 2 hours the rate is changed to 200 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL150 mL/h · 2 h200 mL/h
t = h
35.Clinical assessment scoresMedium
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: no; secondary diagnosis: no; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: yes; gait: impaired; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 87 kg and is 196 cm tall. Calculate the BMI and click the WHO weight category.
87 kg196 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.49, PaCO₂ 39 mmHg (5.2 kPa) and HCO₃⁻ 29 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.49PaCO₂ 39 mmHg (5.2 kPa)HCO₃⁻ 29 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 46 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 46 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
Interpret this lead II rhythm strip. Which rhythm is it? 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
1atrial fibrillation
2sinus bradycardia
3first-degree AV block
4junctional rhythm
40.ECG rhythm strip interpretationHard
Interpret this lead II strip with the five steps in order: rate, rhythm, P waves, PR interval, QRS duration. At which step do you find the first abnormal finding? Click it.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1rate
2rhythm
3P waves
4PR interval
5QRS duration
3Solutions
1.Nursing fundamentals
Answer: D · Increasing redness, warmth, swelling, pain and pus
Why this is the answer
Spreading redness, heat, swelling, pain, pus or an unpleasant smell suggest infection, sometimes with fever. Pink granulation tissue and itching are signs of normal healing.
Answer
D · Increasing redness, warmth, swelling, pain and pus
2.Nursing fundamentals
Answer: D · The systolic may be read too low and the diastolic too high
Why this is the answer
Fast deflation means the gauge drops past the first and last sounds before they are heard. The usual advice is to deflate at about 2–3 mmHg per second.
Answer
D · The systolic may be read too low and the diastolic too high
3.Infection control & patient safety
Answer: A · A second person checking separately catches missed errors
Why this is the answer
In an independent double check, a second qualified person checks the order, the drug, the dose, the calculation and the pump settings on their own. This catches errors that could cause serious harm with high-alert medications.
Answer
A · A second person checking separately catches missed errors
4.Infection control & patient safety
Answer: B · There is no preventive drug, so baseline and follow-up testing are done to detect infection early
Why this is the answer
There is no vaccine or post-exposure prophylaxis for hepatitis C. The exposure is reported, baseline tests are taken and follow-up testing identifies infection early, because effective treatment is available.
Answer
B · There is no preventive drug, so baseline and follow-up testing are done to detect infection early
5.Prioritization & delegation
Answer: C · Say the nurse will come to answer, and tell the nurse
Why this is the answer
Patient teaching about medicines is a nursing responsibility. The assistant passes the question on to the nurse, so the patient gets accurate information that fits their situation.
Answer
C · Say the nurse will come to answer, and tell the nurse
6.Prioritization & delegation
Answer: A · Neurogenic shock
Why this is the answer
Neurogenic shock follows loss of sympathetic tone, causing vasodilation, hypotension and bradycardia with warm skin. Hypovolemic shock usually causes a fast pulse and cool, clammy skin.
Answer
A · Neurogenic shock
7.Clinical nursing
Answer: B · Kidney damage and hearing loss
Why this is the answer
Gentamicin is nephrotoxic and ototoxic. Blood levels and renal function are monitored, and any tinnitus, dizziness or hearing change is reported.
Answer
B · Kidney damage and hearing loss
8.Clinical nursing
Answer: B · Sulfonylureas act for a long time, so hypoglycaemia can recur
Why this is the answer
Sulfonylureas stimulate insulin release and have a long duration of action. Hypoglycaemia can be prolonged or recur, so glucose is monitored closely after treatment.
Answer
B · Sulfonylureas act for a long time, so hypoglycaemia can recur
9.Lab values & electrolytes
Answer: D · The drug can mask warning signs of hypoglycemia
Why this is the answer
Beta-blockers, especially nonselective ones, blunt adrenergic warning signs of hypoglycemia such as tremor and tachycardia, and they can delay recovery. Sweating usually remains. Glucose checks help detect lows that the patient may not feel.Checked against:Low blood sugar · MedlinePlus (NIH) (2026)
Answer
D · The drug can mask warning signs of hypoglycemia
10.Lab values & electrolytes
Answer: A · Several medicines that raise potassium are being taken together
Why this is the answer
ACE inhibitors and spironolactone both make the kidneys retain potassium, and a supplement adds more. The nurse holds the supplement, informs the prescriber and checks kidney function and the ECG.Checked against:High potassium level · MedlinePlus (NIH) (2025); Spironolactone · MedlinePlus (NIH) (2018)
Answer
A · Several medicines that raise potassium are being taken together
11.Pharmacology
Answer: C · Give doses early in the day and monitor appetite and growth
Why this is the answer
Stimulants can cause insomnia, so doses are given in the morning and early afternoon. Reduced appetite can slow growth, so height and weight are tracked.
Answer
C · Give doses early in the day and monitor appetite and growth
12.Pharmacology
Answer: B · 80 mg
Why this is the answer
Loading dose = 40 L × 2 mg/L = 80 mg. The loading dose depends on Vd, while the maintenance dose depends on clearance.
Answer
B · 80 mg
13.Med-surg: cardiovascular & respiratory
Answer: C · Statins reduce further events whatever the starting cholesterol
Why this is the answer
After ACS, high-intensity statin therapy reduces recurrent MI, stroke and death regardless of baseline cholesterol, partly by stabilising plaques. It is part of standard secondary prevention with antiplatelets, beta-blockers, ACE inhibitors and lifestyle change.
Answer
C · Statins reduce further events whatever the starting cholesterol
14.Med-surg: cardiovascular & respiratory
Answer: B · A catheter-related deep vein thrombosis
Why this is the answer
Upper-limb DVT is a recognised complication of PICCs and other central lines. Arm swelling, pain and distended veins should be reported, and an ultrasound arranged. The line is not flushed forcefully, and treatment usually involves anticoagulation.
Answer
B · A catheter-related deep vein thrombosis
15.Med-surg: neuro, endocrine & renal
Answer: B · Glucose tablets or a small glass of fruit juice
Why this is the answer
About 15–20 g of fast-acting carbohydrate, such as glucose tablets or juice, raises glucose quickly. Chocolate and milk contain fat, which slows absorption. Glucose is rechecked after about 15 minutes.
Answer
B · Glucose tablets or a small glass of fruit juice
16.Med-surg: neuro, endocrine & renal
Answer: C · Aspirin
Why this is the answer
Aspirin (salicylates) displaces thyroid hormone from binding proteins, raising free hormone levels. Paracetamol (acetaminophen) and external cooling are used instead, together with treatment for the storm itself.
Answer
C · Aspirin
17.Med-surg: GI, perioperative & oncology
Answer: D · To stop the inner bumper becoming buried in the stomach wall
Why this is the answer
Buried bumper syndrome occurs when the internal fixator embeds in the gastric wall. Following local guidance, the tube is gently advanced, rotated and returned once healed, and the external fixator is kept slightly loose.
Answer
D · To stop the inner bumper becoming buried in the stomach wall
18.Med-surg: GI, perioperative & oncology
Answer: A · Report it, as the regular background dose may need review
Why this is the answer
Regular need for breakthrough doses usually means the background analgesia is inadequate. The prescriber reviews and may adjust the regular dose, while side effects such as sedation are monitored.
Answer
A · Report it, as the regular background dose may need review
19.Maternity & obstetric nursing
Answer: B · A single palmar crease and low tone
Why this is the answer
Features of Down syndrome include hypotonia, upslanting palpebral fissures, a flat nasal bridge, a single palmar crease and a gap between the first and second toes. Heart defects are common, so an echocardiogram is arranged.
Answer
B · A single palmar crease and low tone
20.Maternity & obstetric nursing
Answer: B · A full bladder prevents the uterus from contracting and increases bleeding
Why this is the answer
A distended bladder pushes the uterus up and aside, causing atony and more bleeding. Help her to void, or catheterise per order, then reassess the fundus and the bleeding.
Answer
B · A full bladder prevents the uterus from contracting and increases bleeding
21.Pediatric nursing
Answer: D · Weight that has fallen across two major percentile lines since the last visits
Why this is the answer
A child who grows steadily along a low percentile may simply be small. Crossing two major percentile lines suggests faltering growth and needs assessment of feeding, illness and the social situation.
Answer
D · Weight that has fallen across two major percentile lines since the last visits
22.Pediatric nursing
Answer: B · "If she has a bad reaction, I'll give an antihistamine and wait an hour before using the auto-injector."
Why this is the answer
Adrenaline is the first treatment for anaphylaxis and must be given without delay; antihistamines do not treat airway swelling or shock. Checking expiry dates, reading labels and calling emergency services after use are correct.
Answer
B · "If she has a bad reaction, I'll give an antihistamine and wait an hour before using the auto-injector."
23.Mental health nursing
Answer: B · Spend short, regular periods with the patient without forcing conversation
Why this is the answer
Short, frequent, predictable contacts show acceptance and help build trust. Forcing conversation increases anxiety, while leaving the patient alone can reinforce withdrawal.
Answer
B · Spend short, regular periods with the patient without forcing conversation
24.Mental health nursing
Answer: D · Delusional disorder
Why this is the answer
Delusional disorder involves one or more delusions for at least 1 month, without other prominent symptoms of schizophrenia, and functioning is not markedly impaired apart from the effects of the delusion. Jealous delusions are one recognised type.
Answer
D · Delusional disorder
25.Nursing math & unit conversions
Answer: m = 3.21 kg
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Ounces to pounds
1 oz/16 = 0.0625 lb
7 + 0.0625 = 7.063 lb
Pounds to kilograms
m = 7.063/2.2 = 3.21 kg
Answer
m = 3.21 kg
26.Nursing math & unit conversions
Answer: t = 9 h
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
17:15 → 24:00 = 405 min
After midnight
00:00 → 02:15 = 135 min
Total
405 + 135 = 540 min
t = 540/60 = 9 h
Answer
t = 9 h
27.Dosage calculations
Answer: V = 5 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 10·25 = 250 mg
Volume
V = 250/50 = 5 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 5 mL
28.Dosage calculations
Answer: V₁ = 125 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Volume of stock
V₁ = 2.5·500/10 = 125 mL
Answer
V₁ = 125 mL
29.IV infusion rates
Answer: R = 20 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.
Millilitres per minute
120/60 = 2 mL/min
Drip rate
R = 2·10 = 20 gtt/min
Answer
R = 20 gtt/min
30.IV infusion rates
Answer: D = 3 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
100/500 = 0.2 mg/mL
Dose rate
D = 0.2·15 = 3 mg/h
Answer
D = 3 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 = 7.1 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
800 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
2·94 = 188 mcg/min
188·60 = 11280 mcg/h
Pump rate
R = 11280/1600 = 7.05 ≈ 7.1 mL/h
Answer
R = 7.1 mL/h
33.IV fluids & fluid balance
Answer: I = 1320 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: 150 + 240 + 350 = 740 mL
IV infusion: 60·8 = 480 mL
IV antibiotic: 1·100 = 100 mL
I = 1320 mL
Answer
I = 1320 mL
34.IV fluids & fluid balance
Answer: t = 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.
First part
150·2 = 300 mL
500 − 300 = 200 mL left
Second part
200/200 = 1 h
Total time
t = 2 + 1 = 3 h
Answer
t = 3 h
That is about 3 h 00 min, so the bag runs out at about 22:30.
35.Clinical assessment scores
Answer: MFS = 55
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: no → 0
secondary diagnosis: no → 0
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: yes → 20
gait: impaired → 20
mental status: knows own limits → 0
Add
Morse total = 0 + 0 + 15 + 20 + 20 + 0 = 55
Answer
MFS = 55
36.Clinical assessment scores
Answer: healthy weight
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 87/1.96² = 22.65
Category
healthy weight
Answer
healthy weight
37.Arterial blood gas interpretation
Answer: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.49: alkalaemia (above 7.45)
PaCO₂ 39 mmHg: normal (35–45)
HCO₃⁻ 29 mmol/L: high (22–26)
Compensation
Clinically, also check the expected compensation: for a metabolic alkalosis PaCO₂ ≈ 0.7·HCO₃⁻ + 21 = 39.3–43.3 mmHg, so the measured 39 mmHg points to an additional respiratory alkalosis (a mixed disorder). The answer above is the ROME exam classification.
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 53.2 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.
Expected PaCO₂
0.7·46 + 21 = 53.2 mmHg
Answer
PaCO₂ = 53.2 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: junctional rhythm
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.
Five steps
1. Rate: R–R = 33 small boxes, 1500 ÷ 33 ≈ 45 per minute.
2. Rhythm: regular, every R–R is 1.32 s.
3. P waves: inverted, just after each QRS.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
junctional rhythm
Answer
junctional rhythm
40.ECG rhythm strip interpretation
Answer: rate
Five steps for every strip: 1. rate (300 or 1500 method, or the 6-second method if irregular); 2. rhythm: are the R–R intervals equal; 3. P waves: present, upright in lead II, one before every QRS and all alike; 4. PR interval: 0.12–0.20 s and constant; 5. QRS duration: below 0.12 s. Only after the five steps name the rhythm. Normal sinus rhythm passes all five: 60–100/min, regular, upright P before every QRS, PR 0.12–0.20 s, QRS below 0.12 s.
Five steps
1. Rate: R–R = 12 small boxes, 1500 ÷ 12 ≈ 125 per minute.
2. Rhythm: regular, every R–R is 0.48 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
First abnormal step
rate → sinus tachycardia
Answer
rate
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