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
The skin along a peripheral IV cannula is red, painful and swollen. What is the appropriate action?
AFlush the cannula harder to clear it
BRemove the cannula and document it, then resite if still needed
CCover it with a fresh dressing and continue the infusion as prescribed
DIncrease the infusion rate
2.Nursing fundamentalsHard
Why should a near miss be reported even though no harm occurred?
ABecause insurance companies require a report for every shift worked
BSo the nurse involved can be identified and disciplined
CIt helps find and fix system problems before someone is harmed
DIt does not need reporting if no one was harmed
3.Infection control & patient safetyMedium
During a surgical hand scrub, how are the hands held?
APointing downward into the sink at all times
BAbove the elbows, so water runs from the fingertips toward the elbows
CAt the level of the waist, close to the body
DBelow the elbows, so water runs off the fingertips into the sink
4.Infection control & patient safetyHard
Why can a patient with severe neutropenia have a serious infection but little redness, swelling or pus?
AChemotherapy kills the bacteria before they can multiply
BNeutropenia makes infections stay limited to the skin
CThere are too few neutrophils to produce the usual inflammatory signs
DAntibiotics given with chemotherapy hide all signs of infection
5.Prioritization & delegationMedium
A patient receiving chemotherapy has a temperature of 38.3 °C and a very low neutrophil count. What should the nurse do?
AReport it at once, because cultures and antibiotics are needed quickly
BGive a cool shower and offer extra fluids, then wait and see what happens
CDocument the reading and mention it at the next handover
DRecheck the temperature in four hours before telling anyone
6.Prioritization & delegationHard
An LPN/LVN reports that a stable patient now has new chest pain. What should the RN do?
AAssess the patient personally and decide on the next steps
BTell the LPN/LVN to give the as-needed nitroglycerin without assessment
CAsk the nursing assistant to take an ECG and wait for the result
DAsk the LPN/LVN to handle it and report back at the end of the shift
7.Clinical nursingMedium
Long-term amiodarone treatment can affect which of the following?
AThyroid function, the lungs and the skin's sensitivity to sunlight
BThe sense of smell and taste only, with no other effects
CHair colour and nail growth only, with no effect on organs
DBlood glucose and cholesterol only
8.Clinical nursingHard
A nurse teaches a patient with heart failure about self-care. Which statement shows a need for further teaching?
A"I only need to weigh myself once a month."
B"I will weigh myself each morning after passing urine."
C"I will report it if I need more pillows to sleep."
D"I will take my water tablet in the morning."
9.Lab values & electrolytesMedium
A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?
AStop dialysis for a week and recheck the fluid later
BRecord it as normal and continue the usual exchanges
CSend the fluid for cell count and culture and report it
DAdd more glucose to the next bag to clear the fluid
10.Lab values & electrolytesHard
A patient with alcohol use disorder has a potassium of 3.0 mEq/L despite two days of replacement. The magnesium is 0.9 mEq/L. What is the most appropriate next step?
AGive a diuretic to remove the excess magnesium
BStop all electrolyte replacement for 24 hours and recheck
CReplace the magnesium; low magnesium keeps the kidneys losing potassium
DDouble the potassium dose and leave the magnesium for later
11.PharmacologyMedium
A patient uses two different eye drops at the same time of day. What should the nurse advise?
AMix the drops in one bottle first
BPut both drops in at exactly the same moment
CUse only one of them each day
DWait at least 5 minutes between the two drops
12.PharmacologyHard
A patient is switched from oral to intravenous morphine. Why is the IV dose lower than the oral dose?
AIV morphine is excreted much more slowly by the kidney than oral morphine
BThe oral route causes tolerance faster than the IV route
COral morphine has a large first-pass effect, so less reaches the blood
DIV morphine is a stronger chemical form of the drug
13.Med-surg: cardiovascular & respiratoryMedium
A patient with bronchiectasis of the right lower lobe is taught postural drainage. How should they be positioned?
AWith the affected lobe lowest so it fills with mucus
BWith the affected lobe uppermost so gravity drains it
CFlat on the back with the arms raised
DSitting fully upright at all times
14.Med-surg: cardiovascular & respiratoryHard
After chest trauma, a patient is hypotensive with reduced breath sounds on the left. Which finding suggests a haemothorax rather than a tension pneumothorax?
ADullness to percussion on the affected side
BDistended neck veins
CTrachea pushed away from the affected side
DHyper-resonance on the affected side
15.Med-surg: neuro, endocrine & renalMedium
After IV thrombolysis for stroke, which observations are most important in the first 24 hours?
ABowel sounds and abdominal girth hourly
BDaily weight and the fluid balance only
CFrequent neurological checks and BP
DHourly peak flow and oxygen saturation
16.Med-surg: neuro, endocrine & renalHard
A patient with lung cancer is confused, dehydrated and constipated, with a corrected calcium of 3.4 mmol/L (about 13.6 mg/dL). What is usually the first treatment?
AIV fluids to rehydrate the patient
BA fluid restriction
COral calcium tablets
DIV calcium gluconate and vitamin D
17.Med-surg: GI, perioperative & oncologyMedium
Which burn should usually be discussed with a specialist burns service even if it is small?
AA tiny burn on the forearm with redness only
BA healed burn scar from many years ago
CA small superficial sunburn on the back
DA partial-thickness burn on the hand
18.Med-surg: GI, perioperative & oncologyHard
After surgery, a patient keeps asking for analgesia before it is due, watches the clock and rates pain 8/10. What is the most appropriate interpretation?
AThe patient is addicted and should have analgesia withheld
BPain may be undertreated; reassess and ask for a review of the plan
CThe patient is exaggerating, so the pain scores should be ignored for now
DThe patient needs only distraction and no change in drugs
19.Maternity & obstetric nursingMedium
A woman with a normal pre-pregnancy BMI asks how much weight she should gain. Which range do the widely used US Institute of Medicine guidelines recommend?
AAbout 2 to 4 kg
BAbout 11.5 to 16 kg
CAbout 5 to 9 kg
DAbout 18 to 23 kg
20.Maternity & obstetric nursingHard
A healthy newborn is jittery. Which finding helps tell jitteriness from a seizure?
ASeizures stop when the limb is held
BJitteriness comes with eye deviation and apnoea
CJitteriness stops when the limb is gently held
DSeizures are always triggered by loud sounds
21.Pediatric nursingMedium
Which non-drug measure reduces procedural pain in newborns, for example during a heel prick?
ALeaving the baby alone in the cot
BCold water on the heel before the prick
CBreastfeeding, skin-to-skin contact or oral sucrose
DWaiting until the baby is asleep, without any other comfort
22.Pediatric nursingHard
The parents of a child who is being resuscitated ask to stay in the room. What is the best response?
AAsk them to leave, because their presence always harms the team's work
BTell them to wait outside in the corridor until the resuscitation is over
CAllow them to stay only if they help with the compressions
DAllow them to stay if they wish, with a staff member to support and explain
23.Mental health nursingMedium
A woman calls the emergency department after a sexual assault an hour ago. What advice helps to preserve forensic evidence?
AShower and wash her clothes before coming in, so she feels cleaner
BPut all clothing in a sealed plastic bag
CWait a few days at home until she feels ready to talk before seeking any medical care or forensic examination
DAvoid showering or changing clothes, and bring any clothing already removed in a paper bag
24.Mental health nursingHard
During a session, a patient says he intends to seriously harm a named neighbour. What is the correct general principle?
AConfidentiality means nothing can be shared
BThe threat should be ignored because patients often say things they don't mean
CThe nurse should personally go and warn the neighbour without telling the team
DThe risk to an identifiable person must be shared with the team and may need to be disclosed to protect that person, following the law and policy
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 6:55 PM. Which entry is the same time on the 24-hour clock? Click it.
6:55 PM
106:55
217:55
319:55
418:55
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 19:40 and finishes at 00:20 the next morning (24-hour clock). How many minutes t did it run?
19:4000:20
t = min
27.Dosage calculationsMedium
A patient weighs 60 kg. The prescribed dose is 25 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
60 kg25 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
The prescription is 440 units of a drug that comes as 1000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
440 units1000 units/mL
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 60 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
60 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 200 mg of a drug in 50 mL and runs at 15 mL/h. How many milligrams per hour D does the patient receive?
200 mg/50 mL15 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 60 units/kg for a patient who weighs 102 kg. The vial contains 5 000 units/mL. What volume V do you draw up? Round to one decimal place.
60 units/kg102 kg5 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 400 mg in 250 mL. The order is 3 mcg/kg/min for a patient who weighs 52 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL3 mcg/kg/min52 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.
juice: 100 mLsoup: 180 mLIV infusion: 100 mL/h × 12 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 75 mL/h. At 08:00, 750 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL750 mL infused75 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 16/min, SpO₂ 97% on room air, blood pressure 100/60 mmHg, pulse 88/min, alert, temperature 39.0 °C. What is the NEWS2 total score?
RR 16SpO₂ 97%airSBP 100HR 88AT 39.0 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 12/min, SpO₂ 90% on room air, blood pressure 222/134 mmHg, pulse 58/min, alert, temperature 36.1 °C. Which clinical risk group does the patient fall into? Click it.
RR 12SpO₂ 90%airSBP 222HR 58AT 36.1 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 31 mmHg (4.1 kPa). Use the rule that in chronic respiratory alkalosis HCO₃⁻ falls by 5 mmol/L for every 10 mmHg that PaCO₂ is below 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
At sea level, a practice gas taken on 35% oxygen shows PaO₂ 67 mmHg (8.9 kPa) and PaCO₂ 28 mmHg (3.7 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Fridericia’s formula QTc = QT/∛RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. 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
1second-degree AV block type II
2first-degree AV block
3junctional rhythm
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: B · Remove the cannula and document it, then resite if still needed
Why this is the answer
Phlebitis is inflammation of the vein. The cannula should be removed, the site recorded and monitored, and a new cannula placed elsewhere only if it is still needed.
Answer
B · Remove the cannula and document it, then resite if still needed
2.Nursing fundamentals
Answer: C · It helps find and fix system problems before someone is harmed
Why this is the answer
Near misses show weaknesses in systems, such as confusing packaging or poor checks. Reporting them in a no-blame culture lets the organisation learn and prevent future harm.
Answer
C · It helps find and fix system problems before someone is harmed
3.Infection control & patient safety
Answer: B · Above the elbows, so water runs from the fingertips toward the elbows
Why this is the answer
After a surgical scrub, the hands are the cleanest area, so they are held above the elbows to let water drain away from them toward the less clean elbows.
Answer
B · Above the elbows, so water runs from the fingertips toward the elbows
4.Infection control & patient safety
Answer: C · There are too few neutrophils to produce the usual inflammatory signs
Why this is the answer
Classic signs of infection come from the inflammatory response, which depends on white blood cells. With very few neutrophils, fever may be the only early sign, so it must be taken seriously.
Answer
C · There are too few neutrophils to produce the usual inflammatory signs
5.Prioritization & delegation
Answer: A · Report it at once, because cultures and antibiotics are needed quickly
Why this is the answer
Neutropenic fever is a medical emergency. The patient may have few other signs of infection, so the nurse reports it immediately so that cultures can be taken and IV antibiotics started.
Answer
A · Report it at once, because cultures and antibiotics are needed quickly
6.Prioritization & delegation
Answer: A · Assess the patient personally and decide on the next steps
Why this is the answer
When a stable patient develops a new problem, the RN assesses them, because the patient may now be unstable. The RN then decides on interventions and escalation, which may include an ECG and prescribed nitroglycerin.
Answer
A · Assess the patient personally and decide on the next steps
7.Clinical nursing
Answer: A · Thyroid function, the lungs and the skin's sensitivity to sunlight
Why this is the answer
Amiodarone can cause hypo- or hyperthyroidism, pulmonary fibrosis, liver problems and photosensitivity. Regular monitoring of thyroid and liver function is needed.
Answer
A · Thyroid function, the lungs and the skin's sensitivity to sunlight
8.Clinical nursing
Answer: A · "I only need to weigh myself once a month."
Why this is the answer
Daily weights at the same time with the same scales detect fluid retention early. A rapid gain, worsening breathlessness or needing more pillows should be reported.
Answer
A · "I only need to weigh myself once a month."
9.Lab values & electrolytes
Answer: C · Send the fluid for cell count and culture and report it
Why this is the answer
Cloudy effluent with abdominal pain suggests peritonitis, the main serious complication of peritoneal dialysis. A sample is sent for white cell count, Gram stain and culture, and antibiotics (often given in the dialysis fluid) are started as prescribed.Checked against:Dialysis - peritoneal · MedlinePlus (NIH) (2024)
Answer
C · Send the fluid for cell count and culture and report it
10.Lab values & electrolytes
Answer: C · Replace the magnesium; low magnesium keeps the kidneys losing potassium
Why this is the answer
Low magnesium makes the kidneys lose potassium, so hypokalemia does not correct until the magnesium is replaced. Both are common in alcohol use disorder.Checked against:Low blood potassium · MedlinePlus (NIH) (2025); Magnesium Blood Test · MedlinePlus (NIH) (2023)
Answer
C · Replace the magnesium; low magnesium keeps the kidneys losing potassium
11.Pharmacology
Answer: D · Wait at least 5 minutes between the two drops
Why this is the answer
Waiting several minutes allows the first drop to be absorbed before the next is applied. Eye ointments are usually applied last.
Answer
D · Wait at least 5 minutes between the two drops
12.Pharmacology
Answer: C · Oral morphine has a large first-pass effect, so less reaches the blood
Why this is the answer
Much of an oral morphine dose is metabolised by the liver before reaching the systemic circulation. Equianalgesic tables are used, so the IV dose is a fraction of the oral dose.
Answer
C · Oral morphine has a large first-pass effect, so less reaches the blood
13.Med-surg: cardiovascular & respiratory
Answer: B · With the affected lobe uppermost so gravity drains it
Why this is the answer
Postural drainage places the patient so the affected segment is above the main bronchus, letting gravity move secretions towards the larger airways to be coughed up. It is combined with breathing techniques. Head-down positions are avoided in patients with reflux, recent surgery or breathlessness.
Answer
B · With the affected lobe uppermost so gravity drains it
14.Med-surg: cardiovascular & respiratory
Answer: A · Dullness to percussion on the affected side
Why this is the answer
Blood in the pleural space gives a dull percussion note, whereas air gives hyper-resonance. In haemothorax the neck veins are often flat because of blood loss; in tension pneumothorax they are distended. A massive haemothorax needs a large chest drain, blood replacement and surgical review.
Answer
A · Dullness to percussion on the affected side
15.Med-surg: neuro, endocrine & renal
Answer: C · Frequent neurological checks and BP
Why this is the answer
Neurological observations, blood pressure and checks for bleeding are done frequently after thrombolysis. A new headache, vomiting, falling GCS or rising blood pressure may indicate haemorrhage. Antiplatelets and anticoagulants are usually avoided for 24 hours.
Answer
C · Frequent neurological checks and BP
16.Med-surg: neuro, endocrine & renal
Answer: A · IV fluids to rehydrate the patient
Why this is the answer
Hypercalcaemia causes polyuria and dehydration, which worsen the high calcium. IV fluids are the first step, followed by a bisphosphonate to reduce bone resorption. Calcium is rechecked regularly.
Answer
A · IV fluids to rehydrate the patient
17.Med-surg: GI, perioperative & oncology
Answer: D · A partial-thickness burn on the hand
Why this is the answer
Burns of the face, hands, feet, genitalia, perineum and major joints, as well as circumferential, chemical, electrical and inhalation injuries, usually need specialist advice because of their risks and functional impact.
Answer
D · A partial-thickness burn on the hand
18.Med-surg: GI, perioperative & oncology
Answer: B · Pain may be undertreated; reassess and ask for a review of the plan
Why this is the answer
Clock-watching often reflects inadequate analgesia. The nurse reassesses pain and function, considers multimodal options, and asks the prescriber to review the plan rather than labelling the patient.
Answer
B · Pain may be undertreated; reassess and ask for a review of the plan
19.Maternity & obstetric nursing
Answer: B · About 11.5 to 16 kg
Why this is the answer
For a normal BMI, the US Institute of Medicine (National Academy of Medicine) recommends a total gain of about 11.5 to 16 kg (25 to 35 lb), more for underweight women and less for women with obesity. The UK has no official target range; NICE focuses on healthy eating and activity.
Answer
B · About 11.5 to 16 kg
20.Maternity & obstetric nursing
Answer: C · Jitteriness stops when the limb is gently held
Why this is the answer
Jitteriness is a rhythmic tremor that is stimulus-sensitive and stops when the limb is held or flexed. Seizures continue when restrained and may include eye deviation, apnoea or lip smacking. Glucose and calcium are checked in both.
Answer
C · Jitteriness stops when the limb is gently held
21.Pediatric nursing
Answer: C · Breastfeeding, skin-to-skin contact or oral sucrose
Why this is the answer
Breastfeeding, skin-to-skin care, sucrose with non-nutritive sucking and swaddling all reduce pain responses in newborns. Newborns feel pain and should be protected from it.
Answer
C · Breastfeeding, skin-to-skin contact or oral sucrose
22.Pediatric nursing
Answer: D · Allow them to stay if they wish, with a staff member to support and explain
Why this is the answer
Many families want to be present, and guidelines support offering this with a dedicated staff member to explain and support them. Family presence can help with grief and does not generally interfere with resuscitation.
Answer
D · Allow them to stay if they wish, with a staff member to support and explain
23.Mental health nursing
Answer: D · Avoid showering or changing clothes, and bring any clothing already removed in a paper bag
Why this is the answer
Not washing, changing or eating where possible helps keep evidence. Paper bags are used because plastic traps moisture and can degrade biological evidence. Her medical needs and choices remain the priority.
Answer
D · Avoid showering or changing clothes, and bring any clothing already removed in a paper bag
24.Mental health nursing
Answer: D · The risk to an identifiable person must be shared with the team and may need to be disclosed to protect that person, following the law and policy
Why this is the answer
A serious threat against an identifiable person overrides confidentiality. The nurse informs the team, documents the threat and follows the legal and policy procedures for protecting the person.
Answer
D · The risk to an identifiable person must be shared with the team and may need to be disclosed to protect that person, following the law and policy
25.Nursing math & unit conversions
Answer: 18:55
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.
Convert the hour
6 PM → 6 + 12 = 18
Answer
18:55
Answer
18:55
26.Nursing math & unit conversions
Answer: t = 280 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
19:40 → 24:00 = 260 min
After midnight
00:00 → 00:20 = 20 min
Total
t = 260 + 20 = 280 min
Answer
t = 280 min
27.Dosage calculations
Answer: D = 750 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
25·60 = 1500 mg
Per dose
D = 1500/2 = 750 mg
Answer
D = 750 mg
28.Dosage calculations
Answer: V = 0.44 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.
Volume
V = 440/1000 = 0.44 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.44 mL
29.IV infusion rates
Answer: R = 60 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
60/60 = 1 mL/min
Drip rate
R = 1·60 = 60 gtt/min
Answer
R = 60 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: D = 60 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
200/50 = 4 mg/mL
Dose rate
D = 4·15 = 60 mg/h
Answer
D = 60 mg/h
31.Pediatric & critical-care dosing
Answer: V = 1.2 mL
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 needed
60·102 = 6 120 units
Volume
V = 6120/5000 = 1.224 ≈ 1.2 mL
Answer
V = 1.2 mL
32.Pediatric & critical-care dosing
Answer: R = 5.9 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
400 mg = 400 000 mcg
400 000/250 = 1600 mcg/mL
Dose per minute and per hour
3·52 = 156 mcg/min
156·60 = 9360 mcg/h
Pump rate
R = 9360/1600 = 5.85 ≈ 5.9 mL/h
Answer
R = 5.9 mL/h
33.IV fluids & fluid balance
Answer: I = 1580 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: 100 + 180 = 280 mL
IV infusion: 100·12 = 1200 mL
IV antibiotic: 1·100 = 100 mL
I = 1580 mL
Answer
I = 1580 mL
34.IV fluids & fluid balance
Answer: t = 3.3 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
1000 − 750 = 250 mL
Time
t = 250/75 = 3.333 ≈ 3.3 h
Answer
t = 3.3 h
That is about 3 h 20 min, so the bag runs out at about 11:20.
35.Clinical assessment scores
Answer: NEWS2 = 3
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 16/min → 0
SpO₂ 97% → 0
on air → 0
SBP 100 mmHg → 2
HR 88/min → 0
alert (A) → 0
T 39.0 °C → 1
Add
NEWS2 = 0 + 0 + 0 + 2 + 0 + 0 + 1 = 3
Answer
NEWS2 = 3
36.Clinical assessment scores
Answer: medium
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 12/min → 0
SpO₂ 90% → 3
on air → 0
SBP 222 mmHg → 3
HR 58/min → 0
alert (A) → 0
T 36.1 °C → 0
Total and red scores
NEWS2 = 0 + 3 + 0 + 3 + 0 + 0 + 0 = 6
At least one parameter scores 3.
Risk group
medium
Answer
medium
A total of 5 or more calls for an urgent clinical response.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 19.5 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
|31 − 40| = 9 mmHg → 0.9 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 − 5·0.9 = 19.5 mmol/L
Answer
HCO₃⁻ = 19.5 mmol/L
38.Arterial blood gas interpretation
Answer: A–a gradient = 147.5 mmHg
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.
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
QT = 9.5 × 0.04 = 0.38 s
RR = 26 × 0.04 = 1.04 s
Fridericia’s formula
QTc = 0.38/∛1.04 = 0.38/1.013 = 0.375 s
Answer
QTc = 0.375 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (375 ms)
40.ECG rhythm strip interpretation
Answer: third-degree (complete) AV block
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Five steps
1. Rate: R–R = 27 small boxes, 1500 ÷ 27 ≈ 56 per minute.
2. Rhythm: R–R regular (1.08 s) and P–P regular (0.80 s), but the two are independent.
3. P waves: upright and regular at 75 per minute, but not linked to the QRS complexes; some hide in a QRS or a T wave.
4. PR interval: varies from beat to beat; there is no fixed relation.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
third-degree (complete) AV block
Answer
third-degree (complete) AV block
Type II and third-degree blocks are the ones that can suddenly progress, so textbooks rank them as more serious than type I.
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