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 patient with advanced dementia cannot describe their pain. How should pain be assessed?
AWith an observational pain tool that scores behaviour such as facial expression
BBy assuming there is no pain as long as the patient does not complain or call for help
CBy asking a visitor to guess the pain score
DBy using the 0–10 numeric rating scale only
2.Nursing fundamentalsHard
Vaccinating staff against influenza breaks the chain of infection at which link?
AThe susceptible host
BThe mode of transmission
CThe reservoir
DThe portal of exit
3.Infection control & patient safetyMedium
A nurse finds a used needle in a patient’s bed linen. What should the nurse do?
ARecap it with two hands before throwing it away
BFold it into the linen and send it to the laundry
CPick it up by the hub or with forceps, put it in a sharps container and report it
DLeave it where it is for the housekeeping staff to remove later in the day
4.Infection control & patient safetyHard
A responsive 6-month-old infant is choking and cannot cry or cough. What should the rescuer do?
ATurn the infant upside down and shake gently
BGive abdominal thrusts as for an adult
CGive back blows and chest thrusts in turn
DDo a blind finger sweep of the mouth
5.Prioritization & delegationMedium
A patient receives hemodialysis this morning. Which type of medication is often held before dialysis, as prescribed?
ATopical skin creams
BEye drops for glaucoma
CAntihypertensive drugs
DInhaled bronchodilators
6.Prioritization & delegationHard
On an addiction unit, which patient should the nurse assess first?
AAsking for an extra blanket and a hot drink
BAnxious, with goose bumps, stomach cramps and loose stools
CDrowsy with pinpoint pupils and a respiratory rate of 7/min
DYawning, with a runny nose and dilated pupils
7.Clinical nursingMedium
A patient is started on spironolactone while already taking an ACE inhibitor. Which blood result should be watched most closely?
ASodium, because both drugs raise it sharply
BCalcium, because both drugs lower it
CGlucose, because both drugs cause hyperglycaemia
DPotassium, because both drugs can raise it
8.Clinical nursingHard
A patient has had diarrhoea for three days and is on a medical ward. What is the most appropriate infection control action?
AWait until the diarrhoea has lasted a week before taking any action
BUse alcohol hand rub only and avoid gloves to save resources
CIsolate promptly, use contact precautions and send a stool sample
DMove the patient to a shared bay so single rooms stay available
9.Lab values & electrolytesMedium
A nurse completed the hepatitis B vaccine series. Which result shows protective immunity?
AAnti-HBs of 10 mIU/mL or more
BA positive HBsAg test
CA positive IgM anti-HBc
DA raised ALT level
10.Lab values & electrolytesHard
A patient's results: sodium 140 mEq/L, chloride 100 mEq/L, bicarbonate 12 mEq/L. What is the anion gap, and what does it suggest?
A28 mEq/L, a high anion gap
B40 mEq/L, a high anion gap
C12 mEq/L, a normal anion gap
D52 mEq/L, a very high anion gap
11.PharmacologyMedium
How long does it take, approximately, for a drug given at regular intervals to reach a steady state?
A10 half-lives
B4 to 5 half-lives
C1 half-life
DIt depends only on the dose size
12.PharmacologyHard
Why is intravenous insulin given with glucose in severe hyperkalaemia?
AInsulin protects the heart muscle directly from potassium
BInsulin moves potassium from the blood into cells
CGlucose binds potassium in the blood
DInsulin increases potassium excretion by the kidney
13.Med-surg: cardiovascular & respiratoryMedium
When should an adult with cystic fibrosis take pancreatic enzyme capsules?
AOnly at bedtime
BOnly when they have diarrhoea
COnce a day on waking, at least an hour before any food
DWith all meals and snacks that contain fat
14.Med-surg: cardiovascular & respiratoryHard
A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?
AIt treats infection; the risk is fever
BIt lowers the blood pressure; the main risk is rebound hypertension
CIt improves digestion and gut motility; the main risk is constipation
DIt improves oxygenation; risks are pressure injury and tube displacement
15.Med-surg: neuro, endocrine & renalMedium
Where is the zero point of an external ventricular drain usually levelled?
AAt the top of the head
BAt the tragus of the ear
CAt the mid-axillary line of the chest
DAt the level of the umbilicus
16.Med-surg: neuro, endocrine & renalHard
A patient arrives five hours after the onset of a stroke. A CT angiogram shows a blockage of a large artery in the brain. What is the most appropriate next step?
ANo treatment, because the time for any reperfusion has passed
BUrgent referral for assessment for mechanical thrombectomy
CStart IV alteplase immediately without further imaging
DGive aspirin and plan a review on the ward tomorrow
17.Med-surg: GI, perioperative & oncologyMedium
Why are accurate fluid balance charts kept after major surgery?
ATo decide which meal the patient will have next
BTo record when visitors come and go
CTo check how far the patient has walked and how often they get out of bed
DTo detect dehydration, fluid overload or kidney problems early
18.Med-surg: GI, perioperative & oncologyHard
A patient with advanced cancer who has capacity decides to stop chemotherapy. The family insists that treatment must continue. What should the nurse do?
AAsk the family to sign a new consent form
BTell the patient that stopping is not allowed
CSupport the patient's decision and help the team talk with the family
DContinue treatment because the family has asked for it
19.Maternity & obstetric nursingMedium
A preterm baby on feeds develops a swollen abdomen, bloody stools and feeding intolerance. Which condition is suspected?
ACow's milk protein allergy
BInfantile pyloric stenosis
CNecrotising enterocolitis
DHirschsprung disease
20.Maternity & obstetric nursingHard
A woman at 33 weeks with bright red vaginal bleeding is admitted, and placenta praevia is suspected. Which order should the nurse question?
AInsert a large-bore IV cannula and send a group and screen
BStart continuous fetal heart monitoring
CPerform a digital cervical examination to assess dilation
DArrange an ultrasound to locate the placenta
21.Pediatric nursingMedium
Which advice about screen use reflects common paediatric guidance for children under about 18 months?
AUp to 2 hours a day of educational TV programmes is beneficial for language
BAvoid screen media, apart from video calls with family
CBackground TV helps language development
DScreens are fine as long as the volume is low
22.Pediatric nursingHard
A 25 kg child needs maintenance IV fluids. Using the 100–50–20 rule, what is the hourly rate?
AAbout 50 mL per hour
BAbout 25 mL per hour
CAbout 104 mL per hour
DAbout 67 mL per hour
23.Mental health nursingMedium
A patient intoxicated with phencyclidine (PCP) is agitated and has nystagmus and high blood pressure. Which nursing approach is best?
APut him in a busy area so that staff can watch him more easily
BEncourage him to walk around the ward and join in activities to help burn off the drug
CTry to talk the patient down by discussing his feelings in detail
DProvide a quiet, low-stimulation environment and keep staff and patient safe
24.Mental health nursingHard
A new nurse delegates several tasks to a healthcare assistant. Which delegation shows a need for further teaching?
AAsking the assistant to take routine vital signs of a stable patient
BAsking the assistant to decide whether a patient needs a second dose of a PRN sedative
CAsking the assistant to help a patient with personal hygiene
DAsking the assistant to sit with a calm patient during a group art activity and report any concerns
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 4 lb 13 oz. Using 1 lb = 16 oz and 1 kg = 2.2 lb, find the weight m in kilograms. Round to two decimal places.
4 lb 13 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 4 tbsp of liquid supplement, ¼ cup of tea, 1 tsp of cough syrup. Using the equivalents given, find the total oral intake V in mL.
1 tbsp = 15 mL1 cup = 8 fl oz = 240 mL1 tsp = 5 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 15 kg and is prescribed 25 mg/kg as a single dose. Find the dose D in mg.
15 kg25 mg/kg
D = mg
28.Dosage calculationsHard
An infusion contains 25000 units of a drug in 250 mL. The prescription is 1200 units per hour. At what rate R do you set the pump, in mL/h?
25000 units/250 mL1200 units/h
R = mL/h
29.IV infusion ratesMedium
Infuse 500 mL over 5 hours with a giving set of 15 gtt/mL. Find the drip rate R in drops per minute.
500 mL5 h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 200 mg in 250 mL runs at 6 mL/h. How many micrograms per minute D does the patient receive?
200 mg/250 mL6 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 16 units/kg/h for a patient who weighs 92 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL16 units/kg/h92 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 250 mg in 250 mL runs at 7 mL/h. The patient weighs 53 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL7 mL/h53 kg
D = mcg/kg/min
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 48 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 100 mL/h. At 10:00, 100 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL100 mL infused100 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: yes; gait: weak; mental status: overestimates or forgets limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 75 kg and is 166 cm tall. Calculate the BMI and click the WHO weight category.
75 kg166 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.18, PaCO₂ 67 mmHg (8.9 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory acidosis. How far is it compensated? Click your answer.
pH 7.18PaCO₂ 67 mmHg (8.9 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a respiratory acidosis: pH 7.31, PaCO₂ 74 mmHg (9.9 kPa), HCO₃⁻ 36 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 7.31PaCO₂ 74 mmHg (9.9 kPa)HCO₃⁻ 36 mmol/L
1acute
2chronic
3acute on chronic
39.ECG rhythm strip interpretationMedium
This lead II strip shows sinus rhythm with one pause. Measure the pause, the R–R interval across it, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
pause = s
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. The QRS complexes are regular: find the ventricular rate in beats per minute (1500 method, whole number).
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ventricular rate = bpm
3Solutions
1.Nursing fundamentals
Answer: A · With an observational pain tool that scores behaviour such as facial expression
Why this is the answer
Observational tools score signs such as facial expression, vocalisation, body language and changes in behaviour. People with dementia often have pain that is missed.
Answer
A · With an observational pain tool that scores behaviour such as facial expression
2.Nursing fundamentals
Answer: A · The susceptible host
Why this is the answer
Immunisation makes a person no longer susceptible, so the infection cannot establish itself in them. Hand hygiene, by contrast, breaks the mode of transmission.
Answer
A · The susceptible host
3.Infection control & patient safety
Answer: C · Pick it up by the hub or with forceps, put it in a sharps container and report it
Why this is the answer
A loose needle is a hazard to everyone who handles the linen. The nurse disposes of it safely without recapping, using an instrument if needed, and reports the incident so the cause can be addressed.
Answer
C · Pick it up by the hub or with forceps, put it in a sharps container and report it
4.Infection control & patient safety
Answer: C · Give back blows and chest thrusts in turn
Why this is the answer
For infants under one year, the rescuer alternates sets of back blows with chest thrusts, with the head lower than the chest. Abdominal thrusts are not used in infants, and blind finger sweeps can push the object further in.
Answer
C · Give back blows and chest thrusts in turn
5.Prioritization & delegation
Answer: C · Antihypertensive drugs
Why this is the answer
Removing fluid during dialysis can cause hypotension, so blood pressure drugs are often held before treatment as prescribed. Some drugs are also removed by dialysis and given afterwards.
Answer
C · Antihypertensive drugs
6.Prioritization & delegation
Answer: C · Drowsy with pinpoint pupils and a respiratory rate of 7/min
Why this is the answer
Pinpoint pupils, drowsiness and slow breathing suggest opioid overdose, which can be fatal. Yawning, a runny nose, dilated pupils and cramps are signs of opioid withdrawal, which is distressing but rarely life-threatening.
Answer
C · Drowsy with pinpoint pupils and a respiratory rate of 7/min
7.Clinical nursing
Answer: D · Potassium, because both drugs can raise it
Why this is the answer
Spironolactone and ACE inhibitors both reduce potassium excretion, so the combination can cause dangerous hyperkalaemia. Potassium and renal function should be checked regularly.
Answer
D · Potassium, because both drugs can raise it
8.Clinical nursing
Answer: C · Isolate promptly, use contact precautions and send a stool sample
Why this is the answer
Unexplained diarrhoea may be infective, for example C. difficile or norovirus. Isolation and testing without delay protect other patients.
Answer
C · Isolate promptly, use contact precautions and send a stool sample
9.Lab values & electrolytes
Answer: A · Anti-HBs of 10 mIU/mL or more
Why this is the answer
An anti-HBs level of at least 10 mIU/mL after vaccination indicates protection. HBsAg and IgM anti-HBc indicate infection, not immunity. Health care workers are often tested after vaccination.Checked against:Hepatitis virus panel · MedlinePlus (NIH) (2024)
Answer
A · Anti-HBs of 10 mIU/mL or more
10.Lab values & electrolytes
Answer: A · 28 mEq/L, a high anion gap
Why this is the answer
The anion gap is 140 − (100 + 12) = 28 mEq/L; a typical normal value is about 8–12 mEq/L when potassium is not included. A high anion gap metabolic acidosis suggests unmeasured acids, for example ketones in DKA or lactate in shock.Checked against:Anion Gap Blood Test · MedlinePlus (NIH) (2024)
Answer
A · 28 mEq/L, a high anion gap
11.Pharmacology
Answer: B · 4 to 5 half-lives
Why this is the answer
With repeated dosing, the level approaches steady state after about 4–5 half-lives, whatever the dose. A loading dose can be used to reach it faster.
Answer
B · 4 to 5 half-lives
12.Pharmacology
Answer: B · Insulin moves potassium from the blood into cells
Why this is the answer
Insulin activates the Na⁺/K⁺-ATPase and drives potassium into cells, lowering plasma levels within minutes. Glucose is given to prevent hypoglycaemia. The effect is temporary; potassium must still be removed from the body.
Answer
B · Insulin moves potassium from the blood into cells
13.Med-surg: cardiovascular & respiratory
Answer: D · With all meals and snacks that contain fat
Why this is the answer
In CF, thick secretions block the pancreatic ducts, causing fat malabsorption and fatty stools. Enzyme capsules are taken with every meal and fat-containing snack, with the dose adjusted to fat intake. Fat-soluble vitamins (A, D, E, K) are also supplemented.
Answer
D · With all meals and snacks that contain fat
14.Med-surg: cardiovascular & respiratory
Answer: D · It improves oxygenation; risks are pressure injury and tube displacement
Why this is the answer
Prone positioning improves ventilation–perfusion matching and oxygenation and improves survival in severe ARDS. Turning needs a trained team. Risks include accidental extubation or line removal and pressure damage to the face, chest and knees, so careful positioning and skin checks are essential.
Answer
D · It improves oxygenation; risks are pressure injury and tube displacement
15.Med-surg: neuro, endocrine & renal
Answer: B · At the tragus of the ear
Why this is the answer
The EVD is levelled at the tragus, which approximates the foramen of Monro. If the head of the bed is changed, the drain must be re-levelled, because its height decides how much CSF drains.
Answer
B · At the tragus of the ear
16.Med-surg: neuro, endocrine & renal
Answer: B · Urgent referral for assessment for mechanical thrombectomy
Why this is the answer
IV thrombolysis is usually given within 4.5 hours of onset. Mechanical thrombectomy for a large vessel occlusion can be done later, typically up to 6 hours and in selected patients up to 24 hours, based on imaging. Time still matters, so referral is urgent.
Answer
B · Urgent referral for assessment for mechanical thrombectomy
17.Med-surg: GI, perioperative & oncology
Answer: D · To detect dehydration, fluid overload or kidney problems early
Why this is the answer
Fluid balance charts record IV and oral intake against urine, drains, vomit and NG losses. Trends help detect hypovolaemia, overload and acute kidney injury.
Answer
D · To detect dehydration, fluid overload or kidney problems early
18.Med-surg: GI, perioperative & oncology
Answer: C · Support the patient's decision and help the team talk with the family
Why this is the answer
A competent adult can refuse treatment. The nurse advocates for the patient, supports communication with the family and team, and helps plan symptom control and palliative care.
Answer
C · Support the patient's decision and help the team talk with the family
19.Maternity & obstetric nursing
Answer: C · Necrotising enterocolitis
Why this is the answer
Necrotising enterocolitis mainly affects preterm babies. Signs include abdominal distension, bilious aspirates, bloody stools and instability. Feeds are stopped and the baby is urgently reviewed. Breast milk lowers the risk.
Answer
C · Necrotising enterocolitis
20.Maternity & obstetric nursing
Answer: C · Perform a digital cervical examination to assess dilation
Why this is the answer
A digital vaginal examination is avoided until placenta praevia has been ruled out by ultrasound, because it can trigger severe haemorrhage. The other orders are appropriate.
Answer
C · Perform a digital cervical examination to assess dilation
21.Pediatric nursing
Answer: B · Avoid screen media, apart from video calls with family
Why this is the answer
Young children learn through face-to-face interaction and play. Guidance such as the American Academy of Pediatrics advises avoiding screens other than video chatting under about 18–24 months, and limited, shared, high-quality viewing after that.
Answer
B · Avoid screen media, apart from video calls with family
22.Pediatric nursing
Answer: D · About 67 mL per hour
Why this is the answer
First 10 kg: 1000 mL; next 10 kg: 500 mL; remaining 5 kg: 5 × 20 = 100 mL. Total = 1600 mL per day, and 1600 ÷ 24 ≈ 67 mL per hour.
Answer
D · About 67 mL per hour
23.Mental health nursing
Answer: D · Provide a quiet, low-stimulation environment and keep staff and patient safe
Why this is the answer
PCP can cause agitation, violence, psychosis, nystagmus and hypertension. Reducing stimulation and keeping enough staff present for safety are key; "talking down" is less effective than with other hallucinogens.
Answer
D · Provide a quiet, low-stimulation environment and keep staff and patient safe
24.Mental health nursing
Answer: B · Asking the assistant to decide whether a patient needs a second dose of a PRN sedative
Why this is the answer
Evaluating the effect of a medicine and deciding on further doses require clinical assessment and cannot be delegated. The other tasks are routine and suitable for a trained assistant.
Answer
B · Asking the assistant to decide whether a patient needs a second dose of a PRN sedative
25.Nursing math & unit conversions
Answer: m = 2.19 kg
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Ounces to pounds
13 oz/16 = 0.8125 lb
4 + 0.8125 = 4.813 lb
Pounds to kilograms
m = 4.813/2.2 = 2.188 ≈ 2.19 kg
Answer
m = 2.19 kg
26.Nursing math & unit conversions
Answer: V = 125 mL
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.
Each item in mL
4 tbsp = 4·15 = 60 mL
¼ cup = 0.25·240 = 60 mL
1 tsp = 1·5 = 5 mL
Add
V = 60 + 60 + 5 = 125 mL
Answer
V = 125 mL
27.Dosage calculations
Answer: D = 375 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.
Dose
25·15 = 375 mg
Answer
D = 375 mg
28.Dosage calculations
Answer: R = 12 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
25000/250 = 100 units/mL
Pump rate
R = 1200/100 = 12 mL/h
Answer
R = 12 mL/h
29.IV infusion rates
Answer: R = 25 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Time in minutes
5·60 = 300 min
Drip rate
R = 500·15/300 = 25 gtt/min
Answer
R = 25 gtt/min
30.IV infusion rates
Answer: D = 80 mcg/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
200000 mcg/250 mL = 800 mcg/mL
Dose per hour
6·800 = 4800 mcg/h
Dose per minute
D = 4800/60 = 80 mcg/min
Answer
D = 80 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 36.8 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
16·92 = 1 472 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1472/40 = 36.8 mL/h
Answer
R = 36.8 mL/h
32.Pediatric & critical-care dosing
Answer: D = 2.2 mcg/kg/min
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
250 000/250 = 1000 mcg/mL
Micrograms per minute
7·1000 = 7000 mcg/h
7000/60 = 116.7 mcg/min
Per kilogram
D = 116.7/53 = 2.201 ≈ 2.2 mcg/kg/min
Answer
D = 2.2 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 3.84 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
400 + 350 + 225 + 500 = 1475 mL
Per kilogram per hour
U = 1475/(48·8) = 3.841 ≈ 3.84 mL/kg/h
Answer
U = 3.84 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 9 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 − 100 = 900 mL
Time
t = 900/100 = 9 h
Answer
t = 9 h
That is about 9 h 00 min, so the bag runs out at about 19:00.
35.Clinical assessment scores
Answer: MFS = 85
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: yes → 20
gait: weak → 10
mental status: overestimates or forgets limits → 15
Add
Morse total = 25 + 15 + 0 + 20 + 10 + 15 = 85
Answer
MFS = 85
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 = 75/1.66² = 27.22
Category
overweight
Answer
overweight
37.Arterial blood gas interpretation
Answer: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.18: acidaemia (below 7.35)
PaCO₂ 67 mmHg: high (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
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 + 1·3.4 = 27.4 mmol/L
chronic: 24 + 3.5·3.4 = 35.9 mmol/L
Compare
measured: 36 mmol/L → chronic
Answer
chronic
39.ECG rhythm strip interpretation
Answer: pause = 1.96 s
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).
Measure
49 small boxes from R to R across the pause
Convert
pause = 49 × 0.04 s = 1.96 s
Compare with P–P
1.96 ÷ 0.84 ≈ 2.3 P–P cycles, not a whole number
Answer
pause = 1.96 s
No P wave appears in the pause, and the pause is not a whole number of P–P cycles: sinus arrest. A pause of exactly two or three cycles would point to sinus exit block.
40.ECG rhythm strip interpretation
Answer: ventricular rate = 50 bpm
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.
Atrial rate
P–P = 18 small boxes = 0.72 s → 1500 ÷ 18 = 83.33 ≈ 83 per minute
Ventricular rate
R–R = 30 small boxes = 1.20 s → 1500 ÷ 30 = 50 ≈ 50 per minute
Answer
ventricular rate = 50 bpm
Answer
ventricular rate = 50 bpm
Third-degree block with a narrow-complex junctional escape (usually 40–60 per minute).
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