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
How should a nurse speak to a patient with hearing loss?
ASpeak very fast to keep the message short
BFace the patient and speak clearly at a normal pace
CCover the mouth to stop background noise
DShout loudly from behind the patient so they can hear every word
2.Nursing fundamentalsHard
A patient on regular paracetamol (acetaminophen) also takes an over-the-counter cold and flu remedy. Why is this a concern?
AParacetamol makes cold remedies cause drowsiness
BThere is no concern, as cold remedies contain no drugs
CMany cold remedies also contain paracetamol, risking liver damage
DCold remedies stop paracetamol from working, so the pain will not be controlled
3.Infection control & patient safetyMedium
An adult with hepatitis A is incontinent of stool. Which precautions are used?
AA protective environment with filtered air
BAirborne precautions in a negative-pressure room with the door closed
CDroplet precautions with a surgical mask
DContact precautions in addition to standard precautions
4.Infection control & patient safetyHard
A patient punches a nurse during care. The nurse is not seriously hurt. What should the nurse do?
AGet medical assessment and report the assault according to policy
BRefuse to care for any patient for the rest of the week until the patient is moved
CPunch the patient back in self-defense
DSay nothing, because violence is part of the job
5.Prioritization & delegationMedium
During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?
ASlow the transfusion and recheck in an hour
BGive an antipyretic and continue the transfusion
CFinish the unit quickly through a pressure bag so that the reaction does not last long
DStop the transfusion and keep the IV open with normal saline via new tubing
6.Prioritization & delegationHard
A patient with a central venous catheter suddenly becomes breathless, with chest pain and a falling SpO₂, as the line is being removed. What does the nurse do first?
AFlush the catheter with saline to clear any blockage
BAsk the patient to take slow deep breaths and continue
CSit the patient upright and finish removing the line quickly
DCover the site, turn onto the left side head down, give oxygen and call for help
7.Clinical nursingMedium
Which blood results are typical of Addison's disease (primary adrenal insufficiency)?
ALow haemoglobin and high platelets
BHigh glucose and high calcium
CHigh sodium and low potassium
DLow sodium and high potassium
8.Clinical nursingHard
A patient with acute pancreatitis is in severe epigastric pain radiating to the back. Which nursing care is most important?
AAdequate pain relief, IV fluids and close fluid balance monitoring
BA large fatty meal to stimulate the pancreas
CRestricting all fluids
DStrict bed rest without observations
9.Lab values & electrolytesMedium
A patient receiving chemotherapy has an ANC of 300/µL and a new temperature of 38.3 °C (100.9 °F). What should the nurse do first?
AEncourage oral fluids and record the fever in the chart
BRemove extra blankets and offer a tepid sponge bath
CGive acetaminophen (paracetamol) and recheck the temperature in 4 hours
DReport it at once so cultures and antibiotics start quickly
10.Lab values & electrolytesHard
Which set of results is most typical of iron-deficiency anemia?
ALow hemoglobin, large red cells (high MCV) and high ferritin
BHigh hemoglobin and high hematocrit
CNormal hemoglobin with a high platelet count only
DLow hemoglobin, small red cells (low MCV) and low ferritin
11.PharmacologyMedium
A parent will give a liquid medicine to a child at home. Which advice is safest?
AMix the dose into a full bottle of milk
BUse any kitchen teaspoon
CEstimate the dose by pouring the liquid into a small cup
DUse the oral syringe or measuring cup supplied with it
12.PharmacologyHard
Why is strict aseptic technique and a limited hang time needed for propofol infusions?
AIts lipid emulsion lets bacteria grow if it is contaminated
BPropofol becomes more potent the longer it hangs
CLight exposure changes propofol into an opioid
DPropofol breaks down into a toxic gas after a few hours
13.Med-surg: cardiovascular & respiratoryMedium
Which skin changes around the ankles are typical of chronic venous insufficiency?
ABrown staining, swelling and dry, itchy skin
BPale, shiny, hairless skin with weak pulses
CA sharply defined red patch with fever
DA cold, white foot with no pulse
14.Med-surg: cardiovascular & respiratoryHard
A patient on warfarin for atrial fibrillation is prescribed clarithromycin. Which action is most appropriate?
AStop the warfarin for the whole antibiotic course
BChange nothing, as antibiotics do not affect warfarin
CAsk whether the INR should be checked sooner, as it may rise
DDouble the warfarin dose during the course
15.Med-surg: neuro, endocrine & renalMedium
In a patient with an acute spinal cord injury at C6, which picture suggests neurogenic shock?
AHigh blood pressure, slow pulse and a pounding headache
BLow blood pressure, fast pulse and cold, clammy skin
CLow blood pressure, slow pulse and warm, dry skin
DNormal blood pressure, fast pulse and a high fever
16.Med-surg: neuro, endocrine & renalHard
The nurse has four patients with diabetes. Which one needs to be seen first?
AA patient waiting for a routine HbA1c test
BA patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
CA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating
DA newly diagnosed patient asking about which foods to eat
17.Med-surg: GI, perioperative & oncologyMedium
Which area is used as a quick estimate of 1% of body surface area for small or scattered burns?
AThe examiner's palm including the fingers
BThe patient's hand and forearm
CThe patient's thumbnail
DThe patient's palm including the fingers
18.Med-surg: GI, perioperative & oncologyHard
A patient's ileostomy output is 2.5 L a day. They feel tired and dizzy and are drinking large amounts of water. Which advice is usually appropriate?
AEat only fruit and fruit juice
BStop all drinking for 24 hours
CLimit plain drinks and use an oral rehydration solution
DDrink even more plain water and tea to replace the losses
19.Maternity & obstetric nursingMedium
A woman at 18 weeks asks about safe exercise. Which advice is correct?
AModerate exercise like walking or swimming is encouraged
BContact sports and scuba diving are safe if she did them before
CExercise should be stopped completely during pregnancy
DExercise lying flat on her back is best after 20 weeks
20.Maternity & obstetric nursingHard
A woman attempting a vaginal birth after a previous caesarean suddenly has severe abdominal pain, the fetal heart rate drops sharply and the presenting part can no longer be felt. What is most likely?
ANormal progress into the second stage
BPlacenta praevia
CEarly decelerations from head compression
DUterine rupture
21.Pediatric nursingMedium
A school-age child with asthma uses an inhaled corticosteroid every day. What should the nurse teach?
AStop it as soon as symptoms improve
BUse it only during an asthma attack
CRinse the mouth after each dose and use a spacer
DSwallow the powder with water
22.Pediatric nursingHard
A child has had many hospital admissions with unexplained symptoms. They occur only when the mother is present and stop when the child is apart from her. What should the nurse consider?
AA rare genetic disorder that needs more tests at once
BFabricated or induced illness; follow safeguarding procedures
CThe ward environment or hospital food is causing the symptoms
DThe child is pretending to be ill to avoid school
23.Mental health nursingMedium
When are delirium tremens most likely to start after the last drink?
AAfter 2 weeks
BWithin 1 to 2 hours
CAfter 2 months
DAbout 2 to 4 days (48 to 96 hours)
24.Mental health nursingHard
In the second session of a new therapy group, members argue about rules and one member challenges the leader's authority. How should the leader interpret this?
AThe group has failed and should be ended before anyone is upset
BThe member who challenged the leader should be removed
CIt is a normal stage of group development, to be handled openly and calmly
DThe leader should avoid all conflict by making every decision alone
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 41 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
41 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 19:35 and finishes at 05:40 the next morning (24-hour clock). How many minutes t did it run?
19:3505:40
t = min
27.Dosage calculationsMedium
A patient weighs 12 kg. The prescribed dose is 7.5 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
12 kg7.5 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
An infusion contains 25000 units of a drug in 1000 mL. The prescription is 1500 units per hour. At what rate R do you set the pump, in mL/h?
25000 units/1000 mL1500 units/h
R = mL/h
29.IV infusion ratesMedium
1000 mL was ordered over 10 hours. After 6 hours you find that 440 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
1000 mL / 10 hafter 6 h: 440 mL
R = mL/h
30.IV infusion ratesHard
1500 mL was ordered over 12 hours. After 2 hours you find that 1430 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1500 mL / 12 hafter 2 h: 1430 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 15 units/kg/h for a patient who weighs 57 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL15 units/kg/h57 kg
R = mL/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 4 mcg/kg/min for a patient who weighs 67 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL4 mcg/kg/min67 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. Count ice chips as half their volume.
juice: 200 mLtea: 200 mLice chips: 100 mLIV infusion: 75 mL/h × 12 hIV antibiotic: 1 × 50 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 80 mL/h. At 10:00, 200 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL200 mL infused80 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: completely limited; moisture: constantly moist; activity: walks occasionally; mobility: completely immobile; nutrition: excellent; friction and shear: no apparent problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 70 mmHg. A patient’s systolic pressure is 126 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 70 mmHg?
MAP 70 mmHgSBP 126 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 131 mmol/L, glucose 4.8 mmol/L and urea 14.6 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 131 mmol/Lglucose 4.8 mmol/Lurea 14.6 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.29, PaCO₂ 26 mmHg (3.5 kPa), HCO₃⁻ 12 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.29PaCO₂ 26 mmHg (3.5 kPa)HCO₃⁻ 12 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
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
1sinus arrhythmia
2sinus rhythm with sinus arrest
3normal sinus rhythm
4sinus rhythm with PVCs
40.ECG rhythm strip interpretationHard
Identify the rhythm on this 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
1atrial fibrillation
2torsades de pointes
3ventricular tachycardia
4ventricular fibrillation
3Solutions
1.Nursing fundamentals
Answer: B · Face the patient and speak clearly at a normal pace
Why this is the answer
Facing the patient in good light, reducing background noise and speaking clearly, without shouting, helps understanding. Hearing aids should be in and working.
Answer
B · Face the patient and speak clearly at a normal pace
2.Nursing fundamentals
Answer: C · Many cold remedies also contain paracetamol, risking liver damage
Why this is the answer
Paracetamol is in many combination products. Taking several at once can push the total over the safe daily maximum and cause liver damage, so patients are taught to check labels.
Answer
C · Many cold remedies also contain paracetamol, risking liver damage
3.Infection control & patient safety
Answer: D · Contact precautions in addition to standard precautions
Why this is the answer
Hepatitis A spreads through fecal contamination. For a patient who is incontinent or in diapers, contact precautions are added to standard precautions to prevent spread on hands and surfaces.
Answer
D · Contact precautions in addition to standard precautions
4.Infection control & patient safety
Answer: A · Get medical assessment and report the assault according to policy
Why this is the answer
Workplace violence should always be reported. Reporting allows care for the injured staff member, review of risks and changes to the patient’s care plan to protect staff and other patients.
Answer
A · Get medical assessment and report the assault according to policy
5.Prioritization & delegation
Answer: D · Stop the transfusion and keep the IV open with normal saline via new tubing
Why this is the answer
For any suspected transfusion reaction, the nurse stops the transfusion at once, keeps the vein open with normal saline through new tubing and informs the provider and blood bank.
Answer
D · Stop the transfusion and keep the IV open with normal saline via new tubing
6.Prioritization & delegation
Answer: D · Cover the site, turn onto the left side head down, give oxygen and call for help
Why this is the answer
These signs during line removal suggest an air embolism. Covering the site with an airtight dressing stops more air entering, and the left side, head-down position helps trap air in the right side of the heart, away from the pulmonary artery. Oxygen and urgent help follow.
Answer
D · Cover the site, turn onto the left side head down, give oxygen and call for help
7.Clinical nursing
Answer: D · Low sodium and high potassium
Why this is the answer
Without aldosterone, the kidneys lose sodium and retain potassium. Patients may also have low blood pressure, low glucose and increased skin pigmentation.
Answer
D · Low sodium and high potassium
8.Clinical nursing
Answer: A · Adequate pain relief, IV fluids and close fluid balance monitoring
Why this is the answer
Acute pancreatitis can cause large fluid losses and organ failure. Care focuses on fluid resuscitation, analgesia, monitoring urine output, glucose and early nutrition when possible.
Answer
A · Adequate pain relief, IV fluids and close fluid balance monitoring
9.Lab values & electrolytes
Answer: D · Report it at once so cultures and antibiotics start quickly
Why this is the answer
Neutropenic fever is a medical emergency, because infection can progress to sepsis rapidly without the usual signs of inflammation. Blood cultures are taken and broad-spectrum antibiotics are started promptly as prescribed.Checked against:Watch Out for Fever · CDC (2024); What You Need to Know: Neutropenia and Risk for Infection · CDC
Answer
D · Report it at once so cultures and antibiotics start quickly
10.Lab values & electrolytes
Answer: D · Low hemoglobin, small red cells (low MCV) and low ferritin
Why this is the answer
Iron deficiency causes a microcytic anemia (low MCV) with low iron stores (low ferritin). Large red cells suggest vitamin B12 or folate deficiency.Checked against:Ferritin Blood Test · MedlinePlus (NIH) (2025); RBC indices · MedlinePlus (NIH) (2026)
Answer
D · Low hemoglobin, small red cells (low MCV) and low ferritin
11.Pharmacology
Answer: D · Use the oral syringe or measuring cup supplied with it
Why this is the answer
Kitchen spoons are inaccurate and can cause under- or overdosing. Oral syringes in millilitres are the most accurate, and mixing doses into a whole bottle risks the child not getting the full dose.
Answer
D · Use the oral syringe or measuring cup supplied with it
12.Pharmacology
Answer: A · Its lipid emulsion lets bacteria grow if it is contaminated
Why this is the answer
Propofol is formulated in a soybean oil emulsion, which is a good growth medium for bacteria. Contaminated propofol has caused sepsis, so it is handled aseptically and tubing and containers are changed at set intervals.
Answer
A · Its lipid emulsion lets bacteria grow if it is contaminated
13.Med-surg: cardiovascular & respiratory
Answer: A · Brown staining, swelling and dry, itchy skin
Why this is the answer
High venous pressure causes oedema and leakage of red cells, depositing haemosiderin (brown staining), with venous eczema and lipodermatosclerosis. Pale, shiny, hairless skin suggests arterial disease. Venous ulcers often form above the medial malleolus.
Answer
A · Brown staining, swelling and dry, itchy skin
14.Med-surg: cardiovascular & respiratory
Answer: C · Ask whether the INR should be checked sooner, as it may rise
Why this is the answer
Several antibiotics, including macrolides such as clarithromycin, some fluoroquinolones and co-trimoxazole, can raise the INR and the bleeding risk. Closer INR monitoring and possible dose adjustment are needed. Stopping or doubling warfarin without advice is unsafe.
Answer
C · Ask whether the INR should be checked sooner, as it may rise
15.Med-surg: neuro, endocrine & renal
Answer: C · Low blood pressure, slow pulse and warm, dry skin
Why this is the answer
Neurogenic shock follows injury at T6 or above. Loss of sympathetic tone causes vasodilation (warm, dry skin) and unopposed vagal activity (bradycardia). Hypovolaemic shock causes tachycardia and cold, clammy skin; a trauma patient may have both, so bleeding must still be looked for.
Answer
C · Low blood pressure, slow pulse and warm, dry skin
16.Med-surg: neuro, endocrine & renal
Answer: B · A patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
Why this is the answer
Hypoglycaemia with confusion can rapidly lead to seizures and loss of consciousness, so it is treated at once. A moderately high glucose without symptoms, diet questions and routine tests can wait.
Answer
B · A patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
17.Med-surg: GI, perioperative & oncology
Answer: D · The patient's palm including the fingers
Why this is the answer
The patient's palm with the fingers together is about 1% of their total body surface area. It is useful for small or patchy burns. Simple erythema (superficial burns) is not included in the total.
Answer
D · The patient's palm including the fingers
18.Med-surg: GI, perioperative & oncology
Answer: C · Limit plain drinks and use an oral rehydration solution
Why this is the answer
In high-output stomas, hypotonic drinks increase sodium loss through the stoma. Restricting them and using a glucose–salt oral rehydration solution, with antimotility drugs as prescribed and medical review, helps correct dehydration.
Answer
C · Limit plain drinks and use an oral rehydration solution
19.Maternity & obstetric nursing
Answer: A · Moderate exercise like walking or swimming is encouraged
Why this is the answer
Moderate exercise is safe and beneficial for most pregnant women. Contact sports, activities with a high fall risk and scuba diving are avoided, as is lying flat on the back for long periods later in pregnancy.
Answer
A · Moderate exercise like walking or swimming is encouraged
20.Maternity & obstetric nursing
Answer: D · Uterine rupture
Why this is the answer
Sudden pain, fetal bradycardia and loss of station are classic signs of uterine rupture, a rare but life-threatening emergency that requires immediate surgery.
Answer
D · Uterine rupture
21.Pediatric nursing
Answer: C · Rinse the mouth after each dose and use a spacer
Why this is the answer
Inhaled corticosteroids are preventers, used daily. Rinsing the mouth reduces the risk of oral thrush and hoarseness, and a spacer improves delivery to the lungs. A short-acting reliever is used for attacks.
Answer
C · Rinse the mouth after each dose and use a spacer
22.Pediatric nursing
Answer: B · Fabricated or induced illness; follow safeguarding procedures
Why this is the answer
Fabricated or induced illness (formerly Munchausen syndrome by proxy) is a form of abuse in which a carer invents or causes illness. Careful objective documentation and early involvement of the safeguarding team are essential; the carer should not be confronted alone.
Answer
B · Fabricated or induced illness; follow safeguarding procedures
23.Mental health nursing
Answer: D · About 2 to 4 days (48 to 96 hours)
Why this is the answer
Typical timing: tremor and anxiety from about 6–24 hours, withdrawal seizures from about 12–48 hours and delirium tremens from about 48–96 hours. Timing varies between patients.
Answer
D · About 2 to 4 days (48 to 96 hours)
24.Mental health nursing
Answer: C · It is a normal stage of group development, to be handled openly and calmly
Why this is the answer
Conflict and challenges to the leader are typical of the storming stage. Handling them openly and non-defensively helps the group develop norms and move into productive work.
Answer
C · It is a normal stage of group development, to be handled openly and calmly
25.Nursing math & unit conversions
Answer: T = 105.8 °F
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Multiply by 9/5
41·9/5 = 73.8
Add 32
T = 73.8 + 32 = 105.8 °F
Answer
T = 105.8 °F
26.Nursing math & unit conversions
Answer: t = 605 min
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
19:35 → 24:00 = 265 min
After midnight
00:00 → 05:40 = 340 min
Total
t = 265 + 340 = 605 min
Answer
t = 605 min
27.Dosage calculations
Answer: D = 45 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
7.5·12 = 90 mg
Per dose
D = 90/2 = 45 mg
Answer
D = 45 mg
28.Dosage calculations
Answer: R = 60 mL/h
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration
25000/1000 = 25 units/mL
Pump rate
R = 1500/25 = 60 mL/h
Answer
R = 60 mL/h
29.IV infusion rates
Answer: R = 110 mL/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.
Original rate
1000/10 = 100 mL/h
New rate
R = 440/4 = 110 mL/h
Answer
R = 110 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: Δ = 14.4 %
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.
Original rate
1500/12 = 125 mL/h
New rate
R = 1430/10 = 143 mL/h
Percentage change
Δ = (143 − 125)/125·100% = 14.4%
Answer
Δ = 14.4%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: R = 8.6 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
15·57 = 855 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 855/100 = 8.55 ≈ 8.6 mL/h
Answer
R = 8.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 10.1 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
4·67 = 268 mcg/min
268·60 = 16080 mcg/h
Pump rate
R = 16080/1600 = 10.05 ≈ 10.1 mL/h
Answer
R = 10.1 mL/h
33.IV fluids & fluid balance
Answer: I = 1400 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 + 200 = 400 mL
ice chips: 100/2 = 50 mL
IV infusion: 75·12 = 900 mL
IV antibiotic: 1·50 = 50 mL
I = 1400 mL
Answer
I = 1400 mL
34.IV fluids & fluid balance
Answer: t = 3.8 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 − 200 = 300 mL
Time
t = 300/80 = 3.75 ≈ 3.8 h
Answer
t = 3.8 h
That is about 3 h 45 min, so the bag runs out at about 13:45.
35.Clinical assessment scores
Answer: B = 13
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: completely limited → 1
moisture: constantly moist → 1
activity: walks occasionally → 3
mobility: completely immobile → 1
nutrition: excellent → 4
friction and shear: no apparent problem → 3
Add
Braden total = 1 + 1 + 3 + 1 + 4 + 3 = 13
Answer
B = 13
36.Clinical assessment scores
Answer: DBP = 42 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·70 − 126)/2 = 84/2 = 42 mmHg
Answer
DBP = 42 mmHg
37.Arterial blood gas interpretation
Answer: Osm = 281 mOsm/kg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Calculated osmolality
Osm = 2·131 + 4.8 + 14.6 = 281.4 ≈ 281 mOsm/kg
Answer
Osm = 281 mOsm/kg
38.Arterial blood gas interpretation
Answer: appropriate compensation
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
1.5·12 + 8 = 26 → 24–28 mmHg
Compare
measured: 26 mmHg → appropriate compensation
Answer
appropriate compensation
39.ECG rhythm strip interpretation
Answer: sinus rhythm with sinus arrest
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. Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Five steps
1. Rate: 6 QRS complexes in 6 s, × 10 = 60 per minute.
2. Rhythm: regular (R–R 0.80 s) except for one pause of 1.92 s, which is not a whole number of P–P cycles.
3. P waves: upright, one before every QRS; no P wave at all during the pause.
4. PR interval: 0.16 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
sinus rhythm with sinus arrest
Answer
sinus rhythm with sinus arrest
40.ECG rhythm strip interpretation
Answer: ventricular fibrillation
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
Five steps
1. Rate: no countable ventricular rate.
2. Rhythm: chaotic, no repeating pattern.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: no QRS complexes.
Interpretation
ventricular fibrillation
Answer
ventricular fibrillation
In resuscitation guidelines VF and pulseless VT are the shockable rhythms. This is identification practice only.
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