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
A registered nurse delegates a task to a healthcare assistant. Who is accountable for the decision to delegate?
ANobody, once the task is handed over
BThe patient
COnly the healthcare assistant
DThe registered nurse
2.Nursing fundamentalsHard
Which statement by a visitor shows a need for further teaching about contact precautions?
A"I'll put on the gown and gloves before I go in."
B"I'll clean my hands as I leave the room."
C"I'll take off the gown and gloves before I leave the room."
D"I'll take the gown off at home after I leave the hospital."
3.Infection control & patient safetyMedium
During a norovirus outbreak on a ward, which hand hygiene method should staff use after patient care?
AWashing with soap and water
BAlcohol hand rub only
CNo hand hygiene if gloves were worn
DWiping hands on a paper towel only
4.Infection control & patient safetyHard
A nurse who has a cold sore (herpes labialis) is assigned to the newborn nursery. What is most appropriate?
AWork as usual, since cold sores are very common
BWear gloves and carry on as usual
CInform the manager, who may reassign the nurse for now
DTell no one, and cover the lesion with makeup during shifts
5.Prioritization & delegationMedium
Several patients on a gastroenterology unit need care. Which patient should the nurse see first?
ATwo hours after a colonoscopy: rigid abdomen and severe new pain
BCrohn disease, waiting to be taken down for a scheduled CT scan
CUlcerative colitis, asking about diet changes for home
DLong-standing back pain, asking for the usual analgesic
6.Prioritization & delegationHard
A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?
A“I will tell my doctor if I notice unusual bruising or bleeding.”
B“I will change the injection site each time.”
C“I will rub the area after the injection to help it absorb.”
D“I will inject into the fat of my abdomen, away from the navel.”
7.Clinical nursingMedium
Which group of symptoms suggests hypercalcaemia?
AThirst, constipation, confusion and abdominal pain
BSweating, tremor and sudden hunger
CTingling lips, muscle cramps and spasms of the hands and feet
DWeight gain, feeling cold and a slow pulse
8.Clinical nursingHard
A patient with a confirmed pulmonary embolism is started on anticoagulation. Which statement best explains its purpose?
AIt thins the blood so that the lungs absorb more oxygen
BIt stops the clot growing and prevents new clots while the body breaks it down
CIt is mainly given to lower the blood pressure
DIt dissolves the clot completely within minutes of the first dose being given
9.Lab values & electrolytesMedium
A vancomycin trough level is above the target range. Which adverse effect is the main concern?
AKidney damage (nephrotoxicity)
BLow blood glucose (hypoglycemia)
CA raised platelet count (thrombocytosis)
DConstipation and bloating
10.Lab values & electrolytesHard
A woman with preeclampsia is receiving IV magnesium sulfate. Her urine output has fallen and her creatinine is rising. Why is this a concern?
AMagnesium is broken down by the liver, so it will stop working soon
BMagnesium is excreted by the kidneys, so it can build up to toxic levels
CPoor kidney function makes the magnesium level fall quickly
DMagnesium causes potassium loss, so the kidneys release more fluid
11.PharmacologyMedium
Which fraction of a drug in plasma can reach the receptor and produce an effect?
AThe fraction bound to globulins
BThe fraction bound to albumin
CThe unbound (free) fraction
DThe fraction stored in red blood cells
12.PharmacologyHard
Combining several drugs that prolong the QT interval raises the risk of which life-threatening arrhythmia?
AAtrial fibrillation
BTorsades de pointes
CFirst-degree heart block
DSinus tachycardia
13.Med-surg: cardiovascular & respiratoryMedium
A patient with a regular narrow-complex tachycardia of 180/min is alert with a normal blood pressure. What is usually tried first?
AAn immediate unsynchronised shock with the defibrillator
BA large oral dose of digoxin
CVagal manoeuvres such as a modified Valsalva
DChest compressions until the rate slows
14.Med-surg: cardiovascular & respiratoryHard
A patient regains a pulse after a ventricular fibrillation arrest that was probably caused by a heart attack. Which investigation is most urgent?
AA lumbar puncture
BAn abdominal ultrasound
CSpirometry
DA 12-lead ECG
15.Med-surg: neuro, endocrine & renalMedium
A patient with AKI has a urinary catheter that drains nothing. Which quick bedside check helps rule out a post-renal cause?
AEncourage the patient to drink two litres of water
BCheck the catheter for kinks or blockage and do a bladder scan
CSend a urine sample for culture and wait for the laboratory result
DGive a large bolus of IV fluid straight away
16.Med-surg: neuro, endocrine & renalHard
During a TURP, a patient becomes confused and nauseated, with a slow pulse and a raised BP. The sodium is 121 mmol/L. What is most likely?
AHypoglycaemia from fasting for many hours before surgery
BAn allergic reaction to the catheter
CA normal reaction to the spinal anaesthetic
DTURP syndrome from absorbed irrigation fluid
17.Med-surg: GI, perioperative & oncologyMedium
Which measure helps reduce the risk of delirium in an older surgical patient?
AMoving them to a new bed space each night to reduce boredom
BGiving a sleeping tablet every night
CKeeping the room dark during the day
DMaking sure they have their glasses and hearing aids
18.Med-surg: GI, perioperative & oncologyHard
A patient who takes NSAIDs suddenly develops severe epigastric pain, a rigid abdomen and shoulder-tip pain. Which finding would most support the likely diagnosis?
AFluid levels in the bladder on an ultrasound scan
BA raised serum lipase three times the upper limit
CTall, peaked T waves on a 12-lead ECG
DFree air under the diaphragm on an erect chest X-ray
19.Maternity & obstetric nursingMedium
The fundus is boggy, above the umbilicus and displaced to the right. What is the most likely cause?
AA full bladder
BA normal finding on day 1
CRetained placental tissue on the left
DA tear in the perineum
20.Maternity & obstetric nursingHard
A woman with preterm rupture of membranes at 31 weeks now has a temperature of 38.3 °C, a fetal heart rate baseline of 175 bpm and a tender uterus. What is most likely?
ANormal findings after rupture of membranes
BIntra-amniotic infection (chorioamnionitis)
CPlacenta praevia
DSupine hypotensive syndrome
21.Pediatric nursingMedium
Which signs suggest hypoglycaemia in a young child with diabetes?
AShakiness, sweating, pallor and a sudden change in behaviour
BThirst, passing large amounts of urine and a fruity breath smell
CDeep, rapid breathing with abdominal pain and vomiting
DA slow onset of dry skin and flushed cheeks over several days
22.Pediatric nursingHard
A 10-year-old has vomiting, abdominal pain, deep rapid breathing and a fruity smell on the breath. His blood glucose is very high. What is the most likely diagnosis?
AAppendicitis
BAcute asthma attack with hyperventilation
CGastroenteritis
DDiabetic ketoacidosis
23.Mental health nursingMedium
A patient answers a question about breakfast: "Eggs come from chickens, chickens live on farms, my uncle had a farm, he drove a red tractor…" and never answers. What is this called?
AThought blocking
BTangentiality
CWord salad
DCircumstantiality
24.Mental health nursingHard
A patient with bulimia nervosa has a serum potassium of 2.8 mmol/L. What is the main concern?
AA risk of life-threatening cardiac arrhythmias
BIncreased appetite
CImproved muscle strength
DA risk of weight gain
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 4 ft 0 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
4 ft 0 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 1 tbsp of an oral suspension every 6 hours for 7 days. The suspension comes in 50 mL bottles. Using 1 tbsp = 15 mL, how many whole bottles N must be supplied so the course is complete?
1 tbspevery 6 hours7 days50 mL1 tbsp = 15 mL
N =
27.Dosage calculationsMedium
A prefilled syringe of epinephrine (adrenaline) is labelled 1:10 000 (0.1 mg/mL). The prescription is 1 mg IV in cardiac arrest. What volume V do you give?
1:10 0001 mg
V = mL
28.Dosage calculationsHard
A child weighing 24 kg is prescribed 20 mg/kg per dose of an oral suspension that contains 200 mg in 5 mL. What volume V do you give?
24 kg20 mg/kg200 mg/5 mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 3 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1500 mL3 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
500 mg of a drug is diluted in 250 mL and given by gravity through a set of 60 gtt/mL. The order is 100 mg per hour. Find the drip rate R in drops per minute.
500 mg/250 mL100 mg/h60 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 12 500 units of heparin in 250 mL. The order is 12 units/kg/h for a patient who weighs 96 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
12 500 units/250 mL12 units/kg/h96 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 500 mg in 250 mL. The order is 10 mcg/kg/min for a patient who weighs 56 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
500 mg/250 mL10 mcg/kg/min56 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 patient weighs 104 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
104 kg8 hurine: 150 mLurine: 450 mLwound drain: 60 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 09:00 and runs by pump at 120 mL/h. How many mL V are left in the bag at 10:30?
500 mL120 mL/h09:00 → 10:30
V = mL
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: walks occasionally; mobility: completely immobile; nutrition: adequate; 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). An adult weighs 88 kg and is 178 cm tall. Calculate the BMI and click the WHO weight category.
88 kg178 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 60 mmHg (8.0 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 7.32, PaCO₂ 68 mmHg (9.1 kPa), HCO₃⁻ 34 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 7.32PaCO₂ 68 mmHg (9.1 kPa)HCO₃⁻ 34 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
A monitored patient is found unresponsive and not breathing normally, and no carotid pulse can be felt. The monitor shows this organised rhythm. What is this situation called? 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 tachycardia
2asystole
3pulseless electrical activity (PEA)
4ventricular fibrillation
3Solutions
1.Nursing fundamentals
Answer: D · The registered nurse
Why this is the answer
The nurse is accountable for delegating appropriately, to someone competent, with supervision as needed. The person who accepts the task is accountable for carrying it out properly.
Answer
D · The registered nurse
2.Nursing fundamentals
Answer: D · "I'll take the gown off at home after I leave the hospital."
Why this is the answer
PPE is removed in or at the door of the patient's room and disposed of there, followed by hand hygiene. Wearing it out of the room spreads the organism.
Answer
D · "I'll take the gown off at home after I leave the hospital."
3.Infection control & patient safety
Answer: A · Washing with soap and water
Why this is the answer
Norovirus is not reliably killed by alcohol hand rub, so hands are washed with soap and water, which removes it mechanically. Contact precautions and thorough environmental cleaning are also used.
Answer
A · Washing with soap and water
4.Infection control & patient safety
Answer: C · Inform the manager, who may reassign the nurse for now
Why this is the answer
Herpes simplex can cause severe infection in newborns. Staff with active lesions inform their manager and follow occupational health advice, which often means avoiding contact with newborns and other high-risk patients until the lesion has healed.
Answer
C · Inform the manager, who may reassign the nurse for now
5.Prioritization & delegation
Answer: A · Two hours after a colonoscopy: rigid abdomen and severe new pain
Why this is the answer
A rigid abdomen with severe pain after colonoscopy suggests bowel perforation and peritonitis, a surgical emergency. The other patients have stable, chronic or routine needs.
Answer
A · Two hours after a colonoscopy: rigid abdomen and severe new pain
6.Prioritization & delegation
Answer: C · “I will rub the area after the injection to help it absorb.”
Why this is the answer
Rubbing the site after a low-molecular-weight heparin injection increases bruising. The abdomen away from the navel, rotating sites and reporting bleeding are correct.
Answer
C · “I will rub the area after the injection to help it absorb.”
7.Clinical nursing
Answer: A · Thirst, constipation, confusion and abdominal pain
Why this is the answer
High calcium causes polyuria and thirst, constipation, abdominal pain, kidney stones and confusion. Tingling and cramps suggest low calcium instead.
Answer
A · Thirst, constipation, confusion and abdominal pain
8.Clinical nursing
Answer: B · It stops the clot growing and prevents new clots while the body breaks it down
Why this is the answer
Anticoagulants prevent clot extension and new clots; the body's own fibrinolysis gradually breaks down the existing clot. Thrombolysis, which actively dissolves clots, is reserved for massive PE with shock.
Answer
B · It stops the clot growing and prevents new clots while the body breaks it down
9.Lab values & electrolytes
Answer: A · Kidney damage (nephrotoxicity)
Why this is the answer
High vancomycin levels are linked to acute kidney injury and, less often, hearing damage. The nurse reports the result before the next dose and checks the creatinine and urine output.
Answer
A · Kidney damage (nephrotoxicity)
10.Lab values & electrolytes
Answer: B · Magnesium is excreted by the kidneys, so it can build up to toxic levels
Why this is the answer
Magnesium is cleared by the kidneys, so falling urine output and rising creatinine raise the risk of toxicity. The nurse checks deep tendon reflexes, respiratory rate and level of consciousness, reports the findings and keeps calcium gluconate available as the antidote.
Answer
B · Magnesium is excreted by the kidneys, so it can build up to toxic levels
11.Pharmacology
Answer: C · The unbound (free) fraction
Why this is the answer
Only the free drug can diffuse into tissues, act on receptors and be metabolised or excreted. Protein-bound drug acts as a reservoir.
Answer
C · The unbound (free) fraction
12.Pharmacology
Answer: B · Torsades de pointes
Why this is the answer
A long QT interval delays repolarisation and can trigger torsades de pointes, which may turn into ventricular fibrillation. Drugs such as some macrolides, antipsychotics and antiarrhythmics add to this risk.
Answer
B · Torsades de pointes
13.Med-surg: cardiovascular & respiratory
Answer: C · Vagal manoeuvres such as a modified Valsalva
Why this is the answer
In stable supraventricular tachycardia, vagal manoeuvres slow AV node conduction and can stop the rhythm. If they fail, IV adenosine is usually next. Electrical cardioversion is for patients with adverse features such as shock or chest pain.
Answer
C · Vagal manoeuvres such as a modified Valsalva
14.Med-surg: cardiovascular & respiratory
Answer: D · A 12-lead ECG
Why this is the answer
After return of spontaneous circulation, a 12-lead ECG looks for STEMI, which needs urgent coronary angiography and PCI. Post-resuscitation care also aims for normal oxygen and CO₂ levels, blood pressure support, glucose control and avoiding fever.
Answer
D · A 12-lead ECG
15.Med-surg: neuro, endocrine & renal
Answer: B · Check the catheter for kinks or blockage and do a bladder scan
Why this is the answer
A blocked or kinked catheter or a distended bladder can cause or mimic anuria. Checking the tubing, flushing or changing the catheter as permitted and performing a bladder scan quickly identify obstruction. Ultrasound of the kidneys looks for higher obstruction such as hydronephrosis.
Answer
B · Check the catheter for kinks or blockage and do a bladder scan
16.Med-surg: neuro, endocrine & renal
Answer: D · TURP syndrome from absorbed irrigation fluid
Why this is the answer
In TURP syndrome, irrigating fluid is absorbed into the blood, causing fluid overload and dilutional hyponatraemia. Signs include confusion, nausea, bradycardia, hypertension and, if severe, seizures. It needs urgent medical treatment.
Answer
D · TURP syndrome from absorbed irrigation fluid
17.Med-surg: GI, perioperative & oncology
Answer: D · Making sure they have their glasses and hearing aids
Why this is the answer
Delirium prevention includes using glasses and hearing aids, orientation, good sleep, hydration, nutrition, early mobilisation, pain control, avoiding unnecessary sedatives and involving family.
Answer
D · Making sure they have their glasses and hearing aids
18.Med-surg: GI, perioperative & oncology
Answer: D · Free air under the diaphragm on an erect chest X-ray
Why this is the answer
A perforated peptic ulcer releases air into the peritoneal cavity, seen under the diaphragm on an erect chest X-ray or on CT. Shoulder-tip pain is referred from diaphragmatic irritation. The patient is kept nil by mouth, resuscitated and referred urgently to surgeons.
Answer
D · Free air under the diaphragm on an erect chest X-ray
19.Maternity & obstetric nursing
Answer: A · A full bladder
Why this is the answer
A full bladder lifts and displaces the uterus, usually to the right, and stops it contracting well. Helping the woman to empty her bladder usually lets the fundus return to the midline and firm up.
Answer
A · A full bladder
20.Maternity & obstetric nursing
Answer: B · Intra-amniotic infection (chorioamnionitis)
Why this is the answer
Maternal fever, fetal tachycardia, uterine tenderness and sometimes foul fluid suggest intra-amniotic infection. It needs prompt reporting, antibiotics as prescribed and a plan for birth.
Answer
B · Intra-amniotic infection (chorioamnionitis)
21.Pediatric nursing
Answer: A · Shakiness, sweating, pallor and a sudden change in behaviour
Why this is the answer
Hypoglycaemia causes adrenergic signs (shaking, sweating, pallor, fast heart rate) and neuroglycopenic signs (irritability, confusion, unusual behaviour, drowsiness). Young children may not recognise or report it.
Answer
A · Shakiness, sweating, pallor and a sudden change in behaviour
22.Pediatric nursing
Answer: D · Diabetic ketoacidosis
Why this is the answer
Without insulin the body burns fat, producing ketones that cause metabolic acidosis. Deep, rapid (Kussmaul) breathing, a fruity breath smell, vomiting and abdominal pain with high glucose point to DKA, an emergency.
Answer
D · Diabetic ketoacidosis
23.Mental health nursing
Answer: B · Tangentiality
Why this is the answer
In tangentiality, the speaker drifts away and never reaches the point. In circumstantiality, there are many unnecessary details but the speaker eventually answers. Word salad is a meaningless mix of words.
Answer
B · Tangentiality
24.Mental health nursing
Answer: A · A risk of life-threatening cardiac arrhythmias
Why this is the answer
Repeated vomiting causes hypokalaemia and metabolic alkalosis. A potassium of 2.8 mmol/L is dangerously low and can cause arrhythmias. The patient needs cardiac monitoring and potassium replacement as prescribed.
Answer
A · A risk of life-threatening cardiac arrhythmias
25.Nursing math & unit conversions
Answer: h = 122 cm
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.
Height in inches
4·12 + 0 = 48 in
Inches to centimetres
h = 48·2.54 = 121.9 ≈ 122 cm
Answer
h = 122 cm
26.Nursing math & unit conversions
Answer: N = 9
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.
Total volume
15 mL × 4 × 7 = 420 mL
Bottles
420/50 = 8.4 → N = 9
Answer
N = 9
27.Dosage calculations
Answer: V = 10 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.
Concentration
1:10 000 = 1 g/10000 mL = 0.1 mg/mL
Volume
V = 1/0.1 = 10 mL
Answer
V = 10 mL
US labels now state mg/mL (1 mg/mL = 1:1000; 0.1 mg/mL = 1:10 000). Never give 1 mg/mL epinephrine IV push.
28.Dosage calculations
Answer: V = 12 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
20·24 = 480 mg
Volume
V = (480/200)·5 = 12 mL
Answer
V = 12 mL
29.IV infusion rates
Answer: R = 83 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
3·60 = 180 min
Drip rate
R = 1500·10/180 = 83.33 ≈ 83 gtt/min
Answer
R = 83 gtt/min
At the bedside you round to the nearest whole drop: 83 gtt/min.
30.IV infusion rates
Answer: R = 50 gtt/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
500/250 = 2 mg/mL
Volume per hour
100/2 = 50 mL/h
Drip rate
R = 50·60/60 = 50 gtt/min
Answer
R = 50 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 23 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
12·96 = 1 152 units/h
Concentration
12 500/250 = 50 units/mL
Pump rate
R = 1152/50 = 23.04 ≈ 23 mL/h
Answer
R = 23 mL/h
32.Pediatric & critical-care dosing
Answer: R = 16.8 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
500 mg = 500 000 mcg
500 000/250 = 2000 mcg/mL
Dose per minute and per hour
10·56 = 560 mcg/min
560·60 = 33600 mcg/h
Pump rate
R = 33600/2000 = 16.8 mL/h
Answer
R = 16.8 mL/h
33.IV fluids & fluid balance
Answer: U = 0.72 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
150 + 450 = 600 mL
Per kilogram per hour
U = 600/(104·8) = 0.7212 ≈ 0.72 mL/kg/h
Answer
U = 0.72 mL/kg/h
34.IV fluids & fluid balance
Answer: V = 320 mL
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.
Elapsed time
09:00 → 10:30 = 1.5 h
Volume infused
120·1.5 = 180 mL
Volume left
V = 500 − 180 = 320 mL
Answer
V = 320 mL
35.Clinical assessment scores
Answer: B = 14
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: walks occasionally → 3
mobility: completely immobile → 1
nutrition: adequate → 3
friction and shear: potential problem → 2
Add
Braden total = 2 + 3 + 3 + 1 + 3 + 2 = 14
Answer
B = 14
36.Clinical assessment scores
Answer: overweight
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 = 88/1.78² = 27.77
Category
overweight
Answer
overweight
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 26 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
|60 − 40| = 20 mmHg → 2 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·2 = 26 mmol/L
Answer
HCO₃⁻ = 26 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 + 1·2.8 = 26.8 mmol/L
chronic: 24 + 3.5·2.8 = 33.8 mmol/L
Compare
measured: 34 mmol/L → chronic
Answer
chronic
39.ECG rhythm strip interpretation
Answer: QT = 0.38 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
9.5 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 9.5 × 0.04 s = 0.38 s
Answer
QT = 0.38 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 1.04 s).
40.ECG rhythm strip interpretation
Answer: pulseless electrical activity (PEA)
Pulseless electrical activity (PEA): PEA cannot be seen on a strip. The monitor shows organised electrical activity (a rhythm other than VF, VT or asystole) but the patient has no palpable pulse, so it is recognised by checking the patient. In adult resuscitation guidelines PEA and asystole are the non-shockable cardiac arrest rhythms: high-quality CPR, epinephrine as soon as possible and a search for reversible causes (the Hs and Ts, such as hypovolaemia, hypoxia, tension pneumothorax and cardiac tamponade). VF and pulseless VT are the shockable rhythms.
What the strip shows
1. Rate: R–R = 14 small boxes, 1500 ÷ 14 ≈ 107 per minute.
2. Rhythm: regular, every R–R is 0.56 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.12 s, constant, within 0.12–0.20 s.
5. QRS: 0.06 s, narrow (below 0.12 s).
sinus tachycardia
What the patient shows
no pulse despite organised electrical activity: pulseless electrical activity (PEA), a non-shockable cardiac arrest rhythm
Answer
pulseless electrical activity (PEA)
Answer
pulseless electrical activity (PEA)
PEA is recognised at the bedside, never from the strip alone. This is exam practice, not clinical guidance.