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 the heels of a bedbound patient at high risk be protected?
AWrap them tightly in bandages
BLift them off the mattress with a pillow under the calves
CRest them on a rolled towel placed directly under each heel
DRub them with cream several times a day
2.Nursing fundamentalsHard
A patient has a temperature of 38.7 °C and a white cell count of 18 × 10⁹/L (18,000/mm³). What do these findings most suggest?
AAn infection or significant inflammation
BA low risk of infection because the count is high
CDehydration only
DA normal post-meal result
3.Infection control & patient safetyMedium
A patient with a respiratory infection has a raised procalcitonin level. What does this most suggest?
AA bacterial rather than a viral infection
BAn allergic reaction to a recent medication
CDehydration from poor intake
DA purely viral illness
4.Infection control & patient safetyHard
A patient on long-term high-dose corticosteroids asks for the nasal spray influenza vaccine. What should the nurse explain?
APeople on steroids should never have any influenza vaccine
BEither type is fine, as long as it is given in the morning
CThe nasal spray is the best choice for people on steroids, because it is not injected
DThe nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
5.Prioritization & delegationMedium
A stable adult has abdominal pain and normal vital signs. They will need blood tests and a CT scan. Which ESI level fits?
ALevel 5
BLevel 3
CLevel 4
DLevel 1
6.Prioritization & delegationHard
A competent adult patient refuses a blood transfusion for religious reasons. What should the nurse do?
AAsk the family to persuade the patient until they agree
BTell the patient that refusing treatment is not allowed in hospital
CGive the transfusion while the patient is asleep, because saving their life comes first
DRespect the refusal, check the patient understands the risks and inform the provider
7.Clinical nursingMedium
A new colostomy stoma appears dark purple to black on the second postoperative day. What does this indicate?
APossible ischaemia of the stoma, which needs urgent review
BA normal healthy stoma
CConstipation
DNormal postoperative bruising of the stoma that needs no action
8.Clinical nursingHard
A patient with a spinal cord injury at T4 suddenly develops a pounding headache, very high blood pressure and sweating above the injury. What is the first action?
AGive a sedative and recheck the blood pressure in four hours
BSit the patient up and check for a full bladder or blocked catheter
CLie the patient flat and raise the legs to improve brain perfusion
DGive a large IV fluid bolus and recheck the blood pressure
9.Lab values & electrolytesMedium
A patient with HIV on antiretroviral therapy has an undetectable viral load. What does this mean?
AThe treatment can now be stopped without any risk
BThe virus has been completely cured and removed
CThe treatment is suppressing the virus very well
DThe CD4 count must now be dangerously low too
10.Lab values & electrolytesHard
A patient without symptoms has a TSH of 7.5 mIU/L on two occasions with a normal free T4. Which term fits best?
ASubclinical hyperthyroidism
BSubclinical hypothyroidism
COvert primary hypothyroidism
DSecondary hypothyroidism
11.PharmacologyMedium
Which advice helps reduce the most common side effect of varenicline?
ATake double doses in the first week
BTake it on an empty stomach at bedtime with a little milk
CTake it after food with a full glass of water
DTake it with alcohol to reduce nausea
12.PharmacologyHard
A patient receiving cisplatin is given large volumes of IV fluid before and after each dose. What is the main purpose?
ATo reduce kidney damage
BTo increase drug absorption from the gut
CTo prevent hair loss
DTo prevent bleeding
13.Med-surg: cardiovascular & respiratoryMedium
The monitor shows ventricular fibrillation. The patient is unresponsive and not breathing normally. What is the key treatment?
ACPR and defibrillation as soon as possible
BIV atropine and external pacing
CRapid IV adenosine followed by a flush
DSynchronised cardioversion under deep sedation
14.Med-surg: cardiovascular & respiratoryHard
A patient with rheumatoid arthritis is due to start an anti-TNF biologic drug. Which screening is essential beforehand?
AAn exercise ECG test on a treadmill
BScreening for latent tuberculosis
CA peak flow diary for a month
DA sweat chloride test
15.Med-surg: neuro, endocrine & renalMedium
Which statement about storing insulin is correct?
AInsulin should be kept on a sunny windowsill to stay warm
BAll insulin must be stored in the freezer to keep it stable
CInsulin that has been frozen can be used once it has thawed
DUnopened insulin goes in the fridge and must never be frozen
16.Med-surg: neuro, endocrine & renalHard
A nurse teaches a carer to give buccal midazolam for prolonged seizures. Which statement shows a need for further teaching?
A"I will write down the time the seizure started and the time I gave the dose."
B"I will put something between his teeth so he does not bite his tongue."
C"I will give it into the space between his gum and cheek."
D"I will call an ambulance if the care plan tells me to."
17.Med-surg: GI, perioperative & oncologyMedium
Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?
AA small bruise after a knock
BMild tiredness after a busy day
CNew diarrhoea or abdominal pain
DSlight hair thinning over months
18.Med-surg: GI, perioperative & oncologyHard
A patient with a platelet count of 8 × 109/L (8,000/µL) develops a sudden severe headache and confusion. What should the nurse suspect?
ADehydration from poor intake
BNormal effects of chemotherapy
CIntracranial bleeding
DA tension headache from stress
19.Maternity & obstetric nursingMedium
Misoprostol is given for postpartum haemorrhage. Which side effect is common?
ABradycardia and hypoglycaemia
BSevere hypertension
CBronchospasm in all patients
DShivering and fever
20.Maternity & obstetric nursingHard
A woman with pre-eclampsia has repeated blood pressures of 168/112 mmHg 15 minutes apart. What is the appropriate action?
AGive a large drink of water
BEncourage her to lie flat and rest
CLet her rest quietly on her left side and recheck the blood pressure in 4 hours before reporting
DNotify the provider promptly so antihypertensive treatment can be started without delay
21.Pediatric nursingMedium
After cleft lip repair, which nursing action protects the suture line?
APlace the baby on the stomach to sleep
BLet the baby suck on a dummy straight away
CPosition the baby on the back or side and avoid putting objects in the mouth
DClean the suture line with a dry, rough cloth to remove crusts several times a day
22.Pediatric nursingHard
A child who had a tonsillectomy this morning is swallowing frequently and spitting up bright red blood. What should the nurse do first?
AEncourage the child to gargle
BGive a warm drink to soothe the throat
CAssess the throat and vital signs and notify the surgeon urgently
DRecord it in the notes and reassess at the next routine observation round
23.Mental health nursingMedium
A patient taking phenelzine, an MAOI, is being taught before discharge. Which statement shows a need for further teaching?
A"I'll avoid aged cheese and cured meats."
B"A sudden severe headache is a reason to get help straight away."
C"I can take any cold and flu remedy from the pharmacy."
D"I'll tell any new doctor or dentist that I take an MAOI."
24.Mental health nursingHard
A man whose wife died a month ago is rude and angry with the nurses about small things. What is the best understanding of his behaviour?
AHe should be told that his behaviour is unacceptable and that visits will be stopped
BHis anger may be part of grief, displaced onto staff, so she should not take it personally
CHe has antisocial personality disorder that was not noticed before
DHe does not care about his wife's death and is using it as an excuse to be rude
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 6 ft 5 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
6 ft 5 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 2 fl oz of juice, 2 tsp of cough syrup, ¼ cup of tea. Using the equivalents given, find the total oral intake V in mL.
1 fl oz = 30 mL1 tsp = 5 mL1 cup = 8 fl oz = 240 mL
V = mL
27.Dosage calculationsMedium
A child weighing 32 kg is prescribed 3 mg/kg of a drug. The stock solution contains 20 mg/mL. Draw up the dose: what volume V do you give?
32 kg3 mg/kg20 mg/mL
V = mL
28.Dosage calculationsHard
A child weighing 18 kg is prescribed 10 mg/kg per dose of an oral suspension that contains 200 mg in 5 mL. What volume V do you give?
18 kg10 mg/kg200 mg/5 mL
V = mL
29.IV infusion ratesMedium
A drip runs at 30 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 6 hours?
30 gtt/min15 gtt/mL6 h
V = mL
30.IV infusion ratesHard
1000 mL was ordered over 10 hours. After 7 hours you find that 380 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?
1000 mL / 10 hafter 7 h: 380 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 12 500 units of heparin in 250 mL. The order is 16 units/kg/h for a patient who weighs 58 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
12 500 units/250 mL16 units/kg/h58 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 500 mg in 250 mL runs at 26 mL/h. The patient weighs 90 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
500 mg/250 mL26 mL/h90 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 IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 150 mL/h. At 21:00, 450 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL450 mL infused150 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 9/min, SpO₂ 99% on room air, blood pressure 90/54 mmHg, pulse 110/min, alert, temperature 35.5 °C. What is the NEWS2 total score?
RR 9SpO₂ 99%airSBP 90HR 110AT 35.5 °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 32/min, SpO₂ 99% on supplemental oxygen, blood pressure 106/64 mmHg, pulse 58/min, alert, temperature 35.2 °C. Which clinical risk group does the patient fall into? Click it.
RR 32SpO₂ 99%O₂SBP 106HR 58AT 35.2 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 49 mmHg (6.5 kPa). Use the rule that in acute respiratory acidosis HCO₃⁻ rises by 1 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows pH 7.33, PaCO₂ 33 mmHg (4.4 kPa) and HCO₃⁻ 17 mmol/L, with Na⁺ 135 and Cl⁻ 86 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
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
1supraventricular tachycardia (SVT)
2ventricular tachycardia
3sinus tachycardia
4atrial flutter, 2:1 conduction
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 I (Wenckebach)
2first-degree AV block
3second-degree AV block type II
4sinus bradycardia
3Solutions
1.Nursing fundamentals
Answer: B · Lift them off the mattress with a pillow under the calves
Why this is the answer
Heels have little padding and develop ulcers quickly. "Floating" them, with the support under the calves and the knee slightly bent, removes pressure from the heel.
Answer
B · Lift them off the mattress with a pillow under the calves
2.Nursing fundamentals
Answer: A · An infection or significant inflammation
Why this is the answer
A raised white cell count with fever usually means the body is fighting an infection or major inflammation. The nurse reports it and looks for the source, including sepsis.
Answer
A · An infection or significant inflammation
3.Infection control & patient safety
Answer: A · A bacterial rather than a viral infection
Why this is the answer
Procalcitonin rises mainly in bacterial infections and much less in viral ones. It is used with clinical judgement to help decide when antibiotics are needed or can be stopped.
Answer
A · A bacterial rather than a viral infection
4.Infection control & patient safety
Answer: D · The nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
Why this is the answer
The nasal spray influenza vaccine contains live, weakened virus and is avoided in immunosuppressed people. The inactivated injectable vaccine is safe and recommended for them.
Answer
D · The nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
5.Prioritization & delegation
Answer: B · Level 3
Why this is the answer
Blood tests (one resource) plus a CT scan (a second resource) make two resources, which is ESI level 3 when the vital signs are acceptable.
Answer
B · Level 3
6.Prioritization & delegation
Answer: D · Respect the refusal, check the patient understands the risks and inform the provider
Why this is the answer
Competent adults have the right to refuse treatment, even if it could save their life. The nurse makes sure the refusal is informed, informs the provider and documents it.
Answer
D · Respect the refusal, check the patient understands the risks and inform the provider
7.Clinical nursing
Answer: A · Possible ischaemia of the stoma, which needs urgent review
Why this is the answer
A dusky or black stoma suggests poor blood supply and possible necrosis, and must be reported promptly to the surgical team.
Answer
A · Possible ischaemia of the stoma, which needs urgent review
8.Clinical nursing
Answer: B · Sit the patient up and check for a full bladder or blocked catheter
Why this is the answer
Autonomic dysreflexia occurs with injuries at or above T6. Sitting up lowers blood pressure, and the trigger, most often bladder distension or constipation, must be removed quickly.
Answer
B · Sit the patient up and check for a full bladder or blocked catheter
9.Lab values & electrolytes
Answer: C · The treatment is suppressing the virus very well
Why this is the answer
An undetectable viral load shows that antiretroviral therapy is suppressing viral replication. The virus remains in the body, so treatment must continue. People with a sustained undetectable viral load do not transmit HIV sexually.
Answer
C · The treatment is suppressing the virus very well
10.Lab values & electrolytes
Answer: B · Subclinical hypothyroidism
Why this is the answer
A raised TSH with a normal free T4 is subclinical hypothyroidism; the pituitary is working harder to keep T4 normal. Overt hypothyroidism has a low free T4, and subclinical hyperthyroidism has a low TSH.Checked against:TSH (Thyroid-stimulating hormone) Test · MedlinePlus (NIH) (2024)
Answer
B · Subclinical hypothyroidism
11.Pharmacology
Answer: C · Take it after food with a full glass of water
Why this is the answer
Nausea is the most common adverse effect of varenicline and is reduced by taking it after food with water. Patients should also report changes in mood or behaviour.
Answer
C · Take it after food with a full glass of water
12.Pharmacology
Answer: A · To reduce kidney damage
Why this is the answer
Cisplatin is nephrotoxic, and hydration helps protect the kidneys. It also causes ototoxicity, peripheral neuropathy, severe nausea and low magnesium.
Answer
A · To reduce kidney damage
13.Med-surg: cardiovascular & respiratory
Answer: A · CPR and defibrillation as soon as possible
Why this is the answer
Ventricular fibrillation is a cardiac arrest rhythm. High-quality CPR and early unsynchronised defibrillation are the interventions that improve survival. Synchronised cardioversion is for tachyarrhythmias with a pulse; atropine and pacing are for bradycardia.
Answer
A · CPR and defibrillation as soon as possible
14.Med-surg: cardiovascular & respiratory
Answer: B · Screening for latent tuberculosis
Why this is the answer
TNF-alpha is essential for containing TB in granulomas. Anti-TNF drugs can reactivate latent TB, sometimes as severe disseminated disease. Patients are screened (history, chest X-ray, IGRA) and treated for latent TB before starting.
Answer
B · Screening for latent tuberculosis
15.Med-surg: neuro, endocrine & renal
Answer: D · Unopened insulin goes in the fridge and must never be frozen
Why this is the answer
Unopened insulin is kept in a fridge at about 2–8 °C. Freezing or heat destroys it, so frozen insulin must be thrown away. In-use pens can usually be kept at room temperature for the time stated by the manufacturer.
Answer
D · Unopened insulin goes in the fridge and must never be frozen
16.Med-surg: neuro, endocrine & renal
Answer: B · "I will put something between his teeth so he does not bite his tongue."
Why this is the answer
Nothing should ever be put between the teeth during a seizure. Buccal midazolam is given between the gum and cheek, so the mouth does not need to be forced open. Timing the seizure and following the emergency care plan are correct.
Answer
B · "I will put something between his teeth so he does not bite his tongue."
17.Med-surg: GI, perioperative & oncology
Answer: C · New diarrhoea or abdominal pain
Why this is the answer
Checkpoint inhibitors can cause immune-mediated colitis, pneumonitis, hepatitis, skin reactions and endocrine problems. Early reporting allows grading and treatment, often with corticosteroids.
Answer
C · New diarrhoea or abdominal pain
18.Med-surg: GI, perioperative & oncology
Answer: C · Intracranial bleeding
Why this is the answer
Severe thrombocytopenia carries a risk of spontaneous intracranial haemorrhage. Sudden headache, confusion or neurological change need emergency review, neurological observations and usually urgent imaging and platelet transfusion.
Answer
C · Intracranial bleeding
19.Maternity & obstetric nursing
Answer: D · Shivering and fever
Why this is the answer
Misoprostol, a prostaglandin E1 analogue, commonly causes shivering and a raised temperature, as well as nausea and diarrhoea. It is useful where other uterotonics are not available.
Answer
D · Shivering and fever
20.Maternity & obstetric nursing
Answer: D · Notify the provider promptly so antihypertensive treatment can be started without delay
Why this is the answer
Severe-range hypertension (160 systolic or 110 diastolic or more) in pregnancy raises the risk of stroke and must be treated urgently, ideally within an hour, with drugs such as labetalol, hydralazine or nifedipine as prescribed.
Answer
D · Notify the provider promptly so antihypertensive treatment can be started without delay
21.Pediatric nursing
Answer: C · Position the baby on the back or side and avoid putting objects in the mouth
Why this is the answer
After a lip repair, avoid prone positioning and anything that rubs the suture line. Elbow splints may be used according to the surgeon's instructions. Feed with the method recommended by the team.
Answer
C · Position the baby on the back or side and avoid putting objects in the mouth
22.Pediatric nursing
Answer: C · Assess the throat and vital signs and notify the surgeon urgently
Why this is the answer
Frequent swallowing and bright red blood suggest postoperative haemorrhage. Keep the child upright or on their side, assess vital signs and the throat with a light, and inform the surgeon at once.
Answer
C · Assess the throat and vital signs and notify the surgeon urgently
23.Mental health nursing
Answer: C · "I can take any cold and flu remedy from the pharmacy."
Why this is the answer
Decongestants such as pseudoephedrine are sympathomimetics and can cause a hypertensive crisis with MAOIs. Patients should check any new medicine, including over-the-counter remedies, with a pharmacist or prescriber.
Answer
C · "I can take any cold and flu remedy from the pharmacy."
24.Mental health nursing
Answer: B · His anger may be part of grief, displaced onto staff, so she should not take it personally
Why this is the answer
Anger is a common part of grief and may be directed at staff who are safer targets. The nurse responds calmly, sets limits if needed and invites him to talk about his loss.
Answer
B · His anger may be part of grief, displaced onto staff, so she should not take it personally
25.Nursing math & unit conversions
Answer: h = 196 cm
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Height in inches
6·12 + 5 = 77 in
Inches to centimetres
h = 77·2.54 = 195.6 ≈ 196 cm
Answer
h = 196 cm
26.Nursing math & unit conversions
Answer: V = 130 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
2 fl oz = 2·30 = 60 mL
2 tsp = 2·5 = 10 mL
¼ cup = 0.25·240 = 60 mL
Add
V = 60 + 10 + 60 = 130 mL
Answer
V = 130 mL
27.Dosage calculations
Answer: V = 4.8 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 3·32 = 96 mg
Volume
V = 96/20 = 4.8 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4.8 mL
28.Dosage calculations
Answer: V = 4.5 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose from weight
10·18 = 180 mg
Volume
V = (180/200)·5 = 4.5 mL
Answer
V = 4.5 mL
29.IV infusion rates
Answer: V = 720 mL
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.
Rate in mL/h
30·60/15 = 120 mL/h
Volume
V = 120·6 = 720 mL
Answer
V = 720 mL
30.IV infusion rates
Answer: Δ = 26.67 %
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 = 380/3 = 126.7 mL/h
Percentage change
Δ = (126.7 − 100)/100·100% = 26.67%
Answer
Δ = 26.67%
This is more than a 25% increase: most hospitals require you to contact the prescriber instead of catching up, and to assess the patient for fluid overload.
31.Pediatric & critical-care dosing
Answer: R = 18.6 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
16·58 = 928 units/h
Concentration
12 500/250 = 50 units/mL
Pump rate
R = 928/50 = 18.56 ≈ 18.6 mL/h
Answer
R = 18.6 mL/h
32.Pediatric & critical-care dosing
Answer: D = 9.6 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
500 000/250 = 2000 mcg/mL
Micrograms per minute
26·2000 = 52000 mcg/h
52000/60 = 866.7 mcg/min
Per kilogram
D = 866.7/90 = 9.63 ≈ 9.6 mcg/kg/min
Answer
D = 9.6 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = 855 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.
Total intake
oral: 150 + 120 + 250 = 520 mL
ice chips: 120/2 = 60 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1630 mL
Total output
300 + 250 + 225 = 775 mL
Balance
B = 1630 − 775 = 855 mL
Answer
B = 855 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 3.7 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 − 450 = 550 mL
Time
t = 550/150 = 3.667 ≈ 3.7 h
Answer
t = 3.7 h
That is about 3 h 40 min, so the bag runs out at about 00:40.
35.Clinical assessment scores
Answer: NEWS2 = 6
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 9/min → 1
SpO₂ 99% → 0
on air → 0
SBP 90 mmHg → 3
HR 110/min → 1
alert (A) → 0
T 35.5 °C → 1
Add
NEWS2 = 1 + 0 + 0 + 3 + 1 + 0 + 1 = 6
Answer
NEWS2 = 6
36.Clinical assessment scores
Answer: high
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 32/min → 3
SpO₂ 99% → 0
on oxygen → 2
SBP 106 mmHg → 1
HR 58/min → 0
alert (A) → 0
T 35.2 °C → 1
Total and red scores
NEWS2 = 3 + 0 + 2 + 1 + 0 + 0 + 1 = 7
At least one parameter scores 3.
Risk group
high
Answer
high
A total of 5 or more calls for an urgent clinical response.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 24.9 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
|49 − 40| = 9 mmHg → 0.9 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·0.9 = 24.9 mmol/L
Answer
HCO₃⁻ = 24.9 mmol/L
38.Arterial blood gas interpretation
Answer: added metabolic alkalosis
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.
Anion gap
AG = 135 − (86 + 17) = 32
Delta ratio
(32 − 12)/(24 − 17) = 2.857
added metabolic alkalosis
Answer
added metabolic alkalosis
39.ECG rhythm strip interpretation
Answer: supraventricular tachycardia (SVT)
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: R–R = 8 small boxes, 1500 ÷ 8 ≈ 188 per minute.
2. Rhythm: regular, every R–R is 0.32 s.
3. P waves: none visible; at this rate they are hidden in the QRS complexes or the T waves.
4. PR interval: not measurable.
5. QRS: 0.06 s, narrow (below 0.12 s), so the rhythm starts above the ventricles.
Interpretation
supraventricular tachycardia (SVT)
Answer
supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretation
Answer: second-degree AV block type II
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: 4 QRS complexes in 6 s, × 10 = 40 per minute.
2. Rhythm: the P waves are regular; R–R is regular except for a long pause where a QRS is missing.
3. P waves: upright and regular (P–P 0.96 s, 63 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: constant at 0.18 s in the conducted beats.
5. QRS: 0.14 s, wide (0.12 s or more).
Interpretation
second-degree AV block type II
Answer
second-degree AV block type II
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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