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
When washing a patient's eyes, how should each eye be wiped?
AFrom the outer corner inwards, using the same part of the cloth for both
BOnly the eye that looks dirty needs cleaning
CFrom the inner corner outwards, using a clean part of the cloth for each eye
DIn small circles over the closed eyelid of both eyes
2.Nursing fundamentalsHard
A patient with a valid DNACPR (DNR) decision, whose death was expected, stops breathing. What should the nurse do?
ALeave the patient and ask the family to wait outside until the doctor comes
BStart CPR and call the cardiac arrest team
CStart CPR but stop after five minutes
DNot start CPR, note the time, inform the team and support the family
3.Infection control & patient safetyMedium
Which equipment practice is correct for a patient on contact precautions?
AUsing a dedicated stethoscope and blood pressure cuff for that patient
BUsing the same stethoscope for all patients without cleaning
CUsing equipment from the clean utility room and putting it back unchanged
DTaking the patient’s equipment to the next room
4.Infection control & patient safetyHard
An 84-year-old resident with an indwelling catheter suddenly becomes confused but has no fever. What should the nurse consider?
AA sedative is needed to keep the resident calm
BThe confusion is part of normal aging at this age and needs no further action
CAn infection may present as confusion in older adults, so assess further and report
DInfection can be ruled out because there is no fever
5.Prioritization & delegationMedium
A nurse takes a telephone order from a provider. What must the nurse do?
AWrite the order down and read it back to the provider to confirm it
BRemember the order and write it in the chart at the end of the shift
CCarry out the order first and ask the provider to confirm it later
DAsk the ward clerk to take the order on the nurse’s behalf instead
6.Prioritization & delegationHard
An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?
ALarge-volume IV fluids with close monitoring of urine output
BGiving a high-protein meal to support healing
CApplying antibiotic cream to all the burns before anything else
DStarting physiotherapy to prevent contractures straight away
7.Clinical nursingMedium
What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?
AUse it only after the pain has lasted over an hour, with the patient lying flat
BSit down before using it, as it can cause dizziness and low blood pressure
CTake it with a large glass of milk to protect the stomach lining
DSwallow the spray rather than leaving it under the tongue
8.Clinical nursingHard
A patient on metformin with reduced kidney function is due a CT scan with IV contrast. Why might metformin be withheld?
AMetformin reacts with the contrast to cause severe hyperglycaemia
BMetformin causes severe bleeding during scans
CThere is a risk of lactic acidosis if kidney function worsens
DMetformin makes the images blurry
9.Lab values & electrolytesMedium
Which ECG change is linked to hypocalcemia?
ATall, peaked T waves
BA prominent delta wave
CA prolonged QT interval
DA shortened QT interval
10.Lab values & electrolytesHard
A patient receiving chemotherapy has a white cell count of 1.8 × 10³/µL with 20% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)?
A1,800/µL
B4,500/µL
C360/µL
D450/µL
11.PharmacologyMedium
A prescriber gives a verbal medication order in an emergency. What should the nurse do?
AAsk another nurse to remember the order
BWrite it down and read it back to the prescriber to confirm
CGive the drug without recording the order
DRemember it and write it in the chart at the end of the shift
12.PharmacologyHard
Methotrexate for rheumatoid arthritis is taken once a week. A patient mistakenly takes the same dose every day. What is the main danger?
AThe arthritis gets worse because of drug tolerance
BBone marrow suppression and mucositis from methotrexate toxicity
CHypoglycaemia because methotrexate strongly stimulates insulin release
DSevere hypertension from fluid retention
13.Med-surg: cardiovascular & respiratoryMedium
A patient who had a stroke has a weak swallow. Which measure most reduces the risk of aspiration pneumonia?
AGiving meals while the patient is drowsy
BGiving thin fluids quickly through a straw between meals
CA swallowing assessment and sitting upright for meals
DLying flat for 30 minutes after eating to aid digestion
14.Med-surg: cardiovascular & respiratoryHard
A patient on an unfractionated heparin infusion has a nosebleed that will not stop, and the aPTT is far above the target range. What is the most appropriate action?
AIncrease the infusion, as the aPTT will settle
BStop the infusion, inform the prescriber and anticipate protamine
CContinue the infusion at the same rate and pack the nose firmly
DGive vitamin K and continue the infusion at a slightly lower rate
15.Med-surg: neuro, endocrine & renalMedium
After a change in the levothyroxine dose, when is the TSH usually rechecked?
AAfter about 2 years of treatment
BAfter about 6–8 weeks
CAfter 24 hours
DAfter 3 days
16.Med-surg: neuro, endocrine & renalHard
A patient with trigeminal neuralgia has lost weight and has poor oral hygiene. Which plan is most appropriate?
AOffer soft, lukewarm food and advise chewing on the unaffected side
BEncourage hard, crunchy foods to strengthen the jaw muscles
CAdvise very hot drinks to relax the facial nerves
DTell the patient to stop brushing their teeth completely
17.Med-surg: GI, perioperative & oncologyMedium
Which electrolyte abnormality can contribute to a postoperative ileus?
AHypokalaemia
BHyperkalaemia
CHyperphosphataemia
DHypernatraemia
18.Med-surg: GI, perioperative & oncologyHard
An 80-year-old has a fluid balance 3 L positive two days after surgery. They are now breathless, with crackles at both lung bases and swollen ankles. What should the nurse do?
AEncourage the patient to drink more fluids
BLie the patient flat with the legs raised
CStop the IV fluids, sit the patient up and escalate
DIncrease the IV fluid rate to improve kidney flow
19.Maternity & obstetric nursingMedium
Misoprostol is given for postpartum haemorrhage. Which side effect is common?
ASevere hypertension
BBradycardia and hypoglycaemia
CBronchospasm in all patients
DShivering and fever
20.Maternity & obstetric nursingHard
A woman 2 hours after birth asks for help to the bathroom. She had an epidural that is now off. What is the main safety concern?
AIncreased lochia from walking
BFainting from low blood glucose only
CLeg weakness or numbness causing a fall
DReopening of the epidural site
21.Pediatric nursingMedium
How should the nurse position the ear when giving ear drops to a 2-year-old?
ALeave the pinna alone and tilt the head
BPull the earlobe gently forward and up
CPull the pinna gently down and back
DPull the pinna gently up and back
22.Pediatric nursingHard
Which finding in an infant with suspected reflux needs prompt medical review?
AHiccups after feeds that settle on their own
BSpitting up more after a large feed
CPoor weight gain, refusing feeds and blood in the vomit
DSmall posseting after feeds in a contented, growing baby
23.Mental health nursingMedium
The nurse notices that she is spending much longer with one patient than with the others and feels she is the only one who can help him. What does this most likely indicate?
APossible boundary problems that she should discuss in supervision
BAn ideal therapeutic relationship
CThat the patient needs to be transferred to another unit
DTransference by the patient towards the nurse, which is never the nurse's concern
24.Mental health nursingHard
A malnourished patient with alcohol dependence needs an IV glucose infusion. Which order should the nurse expect first?
AGlucose first, thiamine a week later
BGlucose with no vitamin replacement
CThiamine before or with the glucose
DA diuretic
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 40.6 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
40.6 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 23:50 and finishes at 03:55 the next morning (24-hour clock). How many minutes t did it run?
23:5003:55
t = min
27.Dosage calculationsMedium
A child weighing 32 kg is prescribed 2 mg/kg of a drug. The stock solution contains 40 mg/mL. Draw up the dose: what volume V do you give?
32 kg2 mg/kg40 mg/mL
V = mL
28.Dosage calculationsHard
You must prepare 250 mL of a 5% (w/v) solution from a 20% (w/v) stock solution. What volume of stock V₁ do you need?
C₁ = 20%C₂ = 5%V₂ = 250 mL
V₁ = mL
29.IV infusion ratesMedium
Infuse 1000 mL over 5 hours with a giving set of 15 gtt/mL. Find the drip rate R in drops per minute.
1000 mL5 h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 250 mg of a drug in 250 mL and runs at 12 mL/h. How many milligrams per hour D does the patient receive?
250 mg/250 mL12 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 500 mL. The order is 15 units/kg/h for a patient who weighs 62 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL15 units/kg/h62 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 2.5 mcg/kg/min for a patient who weighs 102 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL2.5 mcg/kg/min102 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 fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 10:15 and runs by pump at 50 mL/h. How many mL V are left in the bag at 14:45?
500 mL50 mL/h10:15 → 14:45
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 98/min and a blood pressure of 90/50 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 98/minBP 90/50 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 59 kg and is 183 cm tall. Calculate the BMI and click the WHO weight category.
59 kg183 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 77 mmHg (10.3 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⁻.
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)
2atrial flutter, 2:1 conduction
3atrial fibrillation
4accelerated junctional rhythm
40.ECG rhythm strip interpretationHard
Interpret this lead II strip with the five steps in order: rate, rhythm, P waves, PR interval, QRS duration. At which step do you find the first abnormal finding? Click it.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1rate
2rhythm
3P waves
4PR interval
5QRS duration
3Solutions
1.Nursing fundamentals
Answer: C · From the inner corner outwards, using a clean part of the cloth for each eye
Why this is the answer
Wiping from the inner to the outer canthus moves debris away from the tear duct. Using a clean part of the cloth for each eye prevents spreading infection between them.
Answer
C · From the inner corner outwards, using a clean part of the cloth for each eye
2.Nursing fundamentals
Answer: D · Not start CPR, note the time, inform the team and support the family
Why this is the answer
CPR is not attempted when a valid DNACPR decision applies. The nurse notes the time, follows local policy for verifying death, informs the medical team and supports the family.
Answer
D · Not start CPR, note the time, inform the team and support the family
3.Infection control & patient safety
Answer: A · Using a dedicated stethoscope and blood pressure cuff for that patient
Why this is the answer
Non-critical equipment such as stethoscopes and cuffs is dedicated to the patient, or cleaned and disinfected before it is used for another patient.
Answer
A · Using a dedicated stethoscope and blood pressure cuff for that patient
4.Infection control & patient safety
Answer: C · An infection may present as confusion in older adults, so assess further and report
Why this is the answer
In older adults, infections such as urinary tract infection may present with new confusion, falls or reduced appetite rather than fever. Sudden confusion is assessed and reported, not dismissed as aging.
Answer
C · An infection may present as confusion in older adults, so assess further and report
5.Prioritization & delegation
Answer: A · Write the order down and read it back to the provider to confirm it
Why this is the answer
For telephone and verbal orders, the nurse writes down the full order and reads it back so the provider can confirm it. This “read-back” prevents errors from mishearing.
Answer
A · Write the order down and read it back to the provider to confirm it
6.Prioritization & delegation
Answer: A · Large-volume IV fluids with close monitoring of urine output
Why this is the answer
Once the airway is secure, the early priority in major burns is fluid resuscitation to prevent burn shock. Urine output is a key guide to whether enough fluid is being given.
Answer
A · Large-volume IV fluids with close monitoring of urine output
7.Clinical nursing
Answer: B · Sit down before using it, as it can cause dizziness and low blood pressure
Why this is the answer
GTN causes vasodilation, which can lead to headache, flushing, dizziness and hypotension. Patients should sit, and seek emergency help if the pain does not settle after the advised doses.
Answer
B · Sit down before using it, as it can cause dizziness and low blood pressure
8.Clinical nursing
Answer: C · There is a risk of lactic acidosis if kidney function worsens
Why this is the answer
Iodinated contrast can worsen kidney function, and metformin can then accumulate and cause lactic acidosis. Local policy guides when to stop and restart it.
Answer
C · There is a risk of lactic acidosis if kidney function worsens
9.Lab values & electrolytes
Answer: C · A prolonged QT interval
Why this is the answer
Low calcium prolongs the QT interval, which can lead to dangerous arrhythmias. High calcium shortens the QT interval, and peaked T waves are typical of hyperkalemia.
Answer
C · A prolonged QT interval
10.Lab values & electrolytes
Answer: D · 450/µL
Why this is the answer
ANC = 1,800 × (0.20 + 0.05) = 450/µL. A value below 500/µL is severe neutropenia with a high risk of serious infection, so neutropenic precautions and early reporting of fever are essential.Checked against:Blood Differential · MedlinePlus (NIH) (2024)
Answer
D · 450/µL
11.Pharmacology
Answer: B · Write it down and read it back to the prescriber to confirm
Why this is the answer
Reading back the drug, dose, route and frequency confirms the order and catches errors. Verbal orders are documented immediately and signed by the prescriber according to policy.
Answer
B · Write it down and read it back to the prescriber to confirm
12.Pharmacology
Answer: B · Bone marrow suppression and mucositis from methotrexate toxicity
Why this is the answer
Methotrexate inhibits dihydrofolate reductase. Daily dosing causes toxicity in dividing tissues such as bone marrow and gut lining, which can be fatal. Folinic acid is used as a rescue treatment.
Answer
B · Bone marrow suppression and mucositis from methotrexate toxicity
13.Med-surg: cardiovascular & respiratory
Answer: C · A swallowing assessment and sitting upright for meals
Why this is the answer
Patients with dysphagia need a formal swallowing assessment, food and fluid textures that are safe for them, sitting upright during and after meals and close supervision. Good oral hygiene also reduces the bacterial load that can be aspirated.
Answer
C · A swallowing assessment and sitting upright for meals
14.Med-surg: cardiovascular & respiratory
Answer: B · Stop the infusion, inform the prescriber and anticipate protamine
Why this is the answer
With bleeding and a high aPTT, the heparin infusion is stopped at once and the prescriber informed. Because heparin's effect wears off within hours, stopping is often enough, but protamine sulfate can reverse it. Vitamin K reverses warfarin, not heparin.
Answer
B · Stop the infusion, inform the prescriber and anticipate protamine
15.Med-surg: neuro, endocrine & renal
Answer: B · After about 6–8 weeks
Why this is the answer
Levothyroxine has a half-life of about a week, so it takes several weeks to reach a new steady state. TSH is usually rechecked about 6–8 weeks after a dose change.
Answer
B · After about 6–8 weeks
16.Med-surg: neuro, endocrine & renal
Answer: A · Offer soft, lukewarm food and advise chewing on the unaffected side
Why this is the answer
Patients may avoid eating and brushing their teeth because these trigger attacks. Soft, lukewarm food, chewing on the unaffected side, gentle oral care and effective drug treatment help maintain nutrition and hygiene.
Answer
A · Offer soft, lukewarm food and advise chewing on the unaffected side
17.Med-surg: GI, perioperative & oncology
Answer: A · Hypokalaemia
Why this is the answer
Low potassium impairs smooth muscle contraction and is a common correctable contributor to ileus. Magnesium and other electrolytes are also checked and corrected.
Answer
A · Hypokalaemia
18.Med-surg: GI, perioperative & oncology
Answer: C · Stop the IV fluids, sit the patient up and escalate
Why this is the answer
Older patients and those with heart or kidney disease can develop fluid overload. The nurse stops fluids, sits the patient up, gives oxygen if needed and asks for medical review, often for diuretics.
Answer
C · Stop the IV fluids, sit the patient up and escalate
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: C · Leg weakness or numbness causing a fall
Why this is the answer
After an epidural, the nurse checks that leg sensation and strength have returned before she stands. Combined with orthostatic hypotension and blood loss, this makes the first walk a high fall risk.
Answer
C · Leg weakness or numbness causing a fall
21.Pediatric nursing
Answer: C · Pull the pinna gently down and back
Why this is the answer
In children under about 3 years the ear canal is short and angled upward, so the pinna is pulled down and back. In older children and adults it is pulled up and back.
Answer
C · Pull the pinna gently down and back
22.Pediatric nursing
Answer: C · Poor weight gain, refusing feeds and blood in the vomit
Why this is the answer
Many babies regurgitate small amounts and grow well; this needs only reassurance. Faltering growth, feed refusal, blood in the vomit, bilious vomiting or breathing problems suggest complications or another diagnosis.
Answer
C · Poor weight gain, refusing feeds and blood in the vomit
23.Mental health nursing
Answer: A · Possible boundary problems that she should discuss in supervision
Why this is the answer
Feeling special or indispensable to one patient, and giving them extra time, are warning signs of over-involvement. Discussing this in clinical supervision helps the nurse keep a therapeutic relationship.
Answer
A · Possible boundary problems that she should discuss in supervision
24.Mental health nursing
Answer: C · Thiamine before or with the glucose
Why this is the answer
Giving glucose to a thiamine-deficient patient can precipitate or worsen Wernicke's encephalopathy. Thiamine is given before or with the glucose, although treatment of hypoglycaemia must not be delayed.
Answer
C · Thiamine before or with the glucose
25.Nursing math & unit conversions
Answer: T = 105.1 °F
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Multiply by 9/5
40.6·9/5 = 73.08
Add 32
T = 73.08 + 32 = 105.1 °F
Answer
T = 105.1 °F
26.Nursing math & unit conversions
Answer: t = 245 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
23:50 → 24:00 = 10 min
After midnight
00:00 → 03:55 = 235 min
Total
t = 10 + 235 = 245 min
Answer
t = 245 min
27.Dosage calculations
Answer: V = 1.6 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 = 2·32 = 64 mg
Volume
V = 64/40 = 1.6 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 1.6 mL
28.Dosage calculations
Answer: V₁ = 62.5 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Volume of stock
V₁ = 5·250/20 = 62.5 mL
Answer
V₁ = 62.5 mL
29.IV infusion rates
Answer: R = 50 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 = 1000·15/300 = 50 gtt/min
Answer
R = 50 gtt/min
30.IV infusion rates
Answer: D = 12 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
250/250 = 1 mg/mL
Dose rate
D = 1·12 = 12 mg/h
Answer
D = 12 mg/h
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
15·62 = 930 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 930/50 = 18.6 mL/h
Answer
R = 18.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 15.3 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
250 mg = 250 000 mcg
250 000/250 = 1000 mcg/mL
Dose per minute and per hour
2.5·102 = 255 mcg/min
255·60 = 15300 mcg/h
Pump rate
R = 15300/1000 = 15.3 mL/h
Answer
R = 15.3 mL/h
33.IV fluids & fluid balance
Answer: B = 280 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: 120 + 100 + 200 = 420 mL
IV infusion: 80·12 = 960 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1580 mL
Total output
350 + 250 + 375 + 325 = 1300 mL
Balance
B = 1580 − 1300 = 280 mL
Answer
B = 280 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 275 mL
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Elapsed time
10:15 → 14:45 = 4.5 h
Volume infused
50·4.5 = 225 mL
Volume left
V = 500 − 225 = 275 mL
Answer
V = 275 mL
35.Clinical assessment scores
Answer: SI = 1.09
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Shock index
SI = 98/90 = 1.089 ≈ 1.09
Answer
SI = 1.09
1 or more: a warning sign of shock in this practice case.
36.Clinical assessment scores
Answer: underweight
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 = 59/1.83² = 17.62
Category
underweight
Answer
underweight
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 27.7 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
|77 − 40| = 37 mmHg → 3.7 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·3.7 = 27.7 mmol/L
Answer
HCO₃⁻ = 27.7 mmol/L
38.Arterial blood gas interpretation
Answer: AGc = 13.25 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.
Anion gap
AG = 140 − (109 + 21) = 10
Correction for albumin
10 + 0.25·(40 − 27) = 13.25 mmol/L
Answer
AGc = 13.25 mmol/L
Above about 12 after correction: a high anion gap.
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 = 6 small boxes, 1500 ÷ 6 ≈ 250 per minute.
2. Rhythm: regular, every R–R is 0.24 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: 0.08 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: rhythm
Five steps for every strip: 1. rate (300 or 1500 method, or the 6-second method if irregular); 2. rhythm: are the R–R intervals equal; 3. P waves: present, upright in lead II, one before every QRS and all alike; 4. PR interval: 0.12–0.20 s and constant; 5. QRS duration: below 0.12 s. Only after the five steps name the rhythm. Normal sinus rhythm passes all five: 60–100/min, regular, upright P before every QRS, PR 0.12–0.20 s, QRS below 0.12 s.
Five steps
1. Rate: 7 QRS complexes in 6 s, × 10 = 70 per minute.
2. Rhythm: irregularly irregular, R–R from 0.68 to 0.98 s with no pattern.
3. P waves: none; the baseline shows small irregular fibrillatory waves.
4. PR interval: not measurable.
5. QRS: 0.10 s, narrow (below 0.12 s).
First abnormal step
rhythm → atrial fibrillation
Answer
rhythm
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