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
Using the AVPU scale, a patient who opens their eyes and groans only when the nurse squeezes their shoulder is scored as:
AP
BA
CV
DU
2.Nursing fundamentalsHard
A colleague asks the nurse to countersign the controlled drug register for a dose the nurse did not see being prepared or given. What should the nurse do?
ARefuse, as they can only sign for what they have witnessed
BSign, but only if the colleague is senior
CSign it later, at the end of the shift, once the colleague explains
DSign, as the colleague is trustworthy
3.Infection control & patient safetyMedium
A patient is on suicide precautions. Which room safety measure is appropriate?
ALet the patient keep a personal razor for shaving, as long as staff are told
BAllow glass bottles if the patient seems calm
CKeep the door closed at all times so the patient has privacy
DRemove items that could be used for self-harm, such as belts and cords
4.Infection control & patient safetyHard
A responsive 6-month-old infant is choking and cannot cry or cough. What should the rescuer do?
ADo a blind finger sweep of the mouth
BTurn the infant upside down and shake gently
CGive back blows and chest thrusts in turn
DGive abdominal thrusts as for an adult
5.Prioritization & delegationMedium
A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?
AStop all insulin until the patient is able to eat normally again
BWait until tomorrow to see if the vomiting settles
CCheck the blood glucose and ketones and contact the provider
DEncourage a large meal to settle the stomach
6.Prioritization & delegationHard
A patient is receiving parenteral nutrition through a central line. Which finding needs immediate action?
AA dry, intact dressing over the line
BA glucose of 150 mg/dL (8.3 mmol/L) while the infusion is running
CSweating, shakiness and a glucose of 62 mg/dL (3.4 mmol/L) after the infusion stopped unexpectedly
DA weight gain of 0.2 kg since yesterday
7.Clinical nursingMedium
Why are patients encouraged to use an incentive spirometer after abdominal surgery?
ATo strengthen the abdominal muscles around the wound
BTo encourage deep breaths that prevent atelectasis and chest infection
CTo lower their heart rate before mobilising
DTo measure their lung function so the result can go in the discharge letter
8.Clinical nursingHard
Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?
AEnteral syringes measure doses less accurately
BEnteral syringes keep the medicine sterile
CTo prevent accidental intravenous administration
DIV syringes cannot hold liquid medicines
9.Lab values & electrolytesMedium
Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?
ABack pain with dark red urine output
BHives and itching without other signs
CA low temperature and slow heart rate
DCrackles, hypertension and a raised BNP
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?
A40 mEq/L, a high anion gap
B12 mEq/L, a normal anion gap
C52 mEq/L, a very high anion gap
D28 mEq/L, a high anion gap
11.PharmacologyMedium
A patient with a fentanyl patch is given home-care advice. Which instruction is correct?
ACut the patch in half if the pain is mild
BThrow used patches loose into the household bin with the packaging
CApply each new patch over the same skin area
DAvoid heating pads, hot baths and saunas over or near the patch
12.PharmacologyHard
Which heart failure drug improves symptoms and reduces hospital admissions but has not been shown to reduce mortality?
AA beta blocker such as bisoprolol
BDigoxin
CA mineralocorticoid receptor antagonist such as spironolactone
DAn ACE inhibitor
13.Med-surg: cardiovascular & respiratoryMedium
After an acute coronary syndrome, a patient with a normal cholesterol level is prescribed a high-intensity statin. Why?
AStatins are needed only if the cholesterol level is very high
BStatins work as painkillers for chest pain
CStatins reduce further events whatever the starting cholesterol
DStatins are given after an ACS mainly to lower the blood pressure
14.Med-surg: cardiovascular & respiratoryHard
A breathless patient on a non-rebreather mask at 15 L/min has a reservoir bag that collapses completely with each breath. What should the nurse do?
AReduce the flow to 2 L/min to stop the bag collapsing
BRemove the bag, as the mask works without it
CLeave it, because a collapsing bag shows a good seal
DCheck the oxygen supply and flow so the bag stays inflated
15.Med-surg: neuro, endocrine & renalMedium
Which blood gas pattern is typical of acute kidney injury?
ALow pH and low bicarbonate
BHigh pH and low carbon dioxide
CLow pH and high carbon dioxide only
DHigh pH and high bicarbonate
16.Med-surg: neuro, endocrine & renalHard
A haemodialysis patient with a tunnelled central venous catheter develops fever and rigors soon after dialysis starts. What should the nurse suspect and do?
ANormal reaction to dialysis; continue and give paracetamol only
BCatheter-related bloodstream infection; stop, take cultures and escalate
CDialysis disequilibrium; speed up dialysis to finish sooner
DAir embolism; tilt the patient head-up and continue
17.Med-surg: GI, perioperative & oncologyMedium
Which signs suggest severe acute pancreatitis with bleeding into the tissues?
ASwelling of the lips, tongue and face
BA purple rash on the palms and soles
CBruising around the umbilicus or flanks
DYellow discolouration of the fingernails
18.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient with chronic pancreatitis. Which statement shows a need for further teaching?
A"I'll report increased thirst or passing urine more often."
B"I'll take my enzyme capsules at bedtime."
C"Oily, floating stools may mean my dose needs changing."
D"I should not drink any alcohol."
19.Maternity & obstetric nursingMedium
During newborn resuscitation, what is the ratio of chest compressions to breaths?
A30 compressions to 2 breaths
B3 compressions to 1 breath
C5 compressions to 1 breath
D15 compressions to 2 breaths
20.Maternity & obstetric nursingHard
At a booking visit, a woman says she drinks heavily most weekends. Which nursing response is most appropriate?
AAdvise her to change to beer, which has less alcohol
BTell her the damage is done, so stopping will not help
CReassure her that weekend drinking is safe if she avoids weekdays
DExplain the risks and refer her for support to stop
21.Pediatric nursingMedium
Which treatment is commonly used for a child with moderate croup?
AA cough suppressant
BA single dose of an oral corticosteroid such as dexamethasone
CA course of oral antibiotics such as amoxicillin for 5 to 7 days
DChest physiotherapy
22.Pediatric nursingHard
A few weeks after diagnosis of type 1 diabetes, a child's insulin needs fall a lot. The parents think the diabetes is cured. What should the nurse explain?
AThe diabetes has turned into type 2 diabetes
BThe child has become insulin resistant and now needs tablets instead of injections
CThis is the temporary "honeymoon" phase; insulin is still needed
DThe diagnosis was probably wrong, and insulin can be stopped
23.Mental health nursingMedium
Which medicine is most likely to raise a patient's lithium level?
AParacetamol (acetaminophen)
BOmeprazole
CIbuprofen
DAmoxicillin
24.Mental health nursingHard
An 80-year-old surgical patient becomes confused overnight, with fluctuating attention and pulling at his IV line. He was well oriented on admission. What is the most appropriate interpretation?
ABad behaviour that needs restraint immediately
BRapid progression of dementia that cannot be treated, so no further tests are needed
CNormal ageing that needs no action
DProbable delirium: look for an underlying physical cause and inform the team
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 11:20 PM. Which entry is the same time on the 24-hour clock? Click it.
11:20 PM
122:20
223:20
300:20
411:20
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 20:35 and finishes at 04:55 the next morning (24-hour clock). How many hours t did it run? Give the answer in hours as a decimal, rounded to two decimal places.
20:3504:55
t = h
27.Dosage calculationsMedium
An ampoule of epinephrine (adrenaline) is labelled 1:1000 (1 mg/mL). The prescription is 0.5 mg IM for anaphylaxis. What volume V do you draw up?
1:10000.5 mg
V = mL
28.Dosage calculationsHard
An infusion contains 40000 units of a drug in 1000 mL. The prescription is 1200 units per hour. At what rate R do you set the pump, in mL/h?
40000 units/1000 mL1200 units/h
R = mL/h
29.IV infusion ratesMedium
Infuse 1500 mL over 5 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute.
1500 mL5 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 400 mg of a drug in 50 mL and runs at 25 mL/h. How many milligrams per hour D does the patient receive?
400 mg/50 mL25 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 250 mL. The order is 1 unit/h. Find the pump rate R in mL/h. Round to one decimal place.
100 units/250 mL1 units/h
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 5 mcg/kg/min for a patient who weighs 58 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL5 mcg/kg/min58 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 13:00 at 80 mL/h. After 3 hours the rate is changed to 50 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL80 mL/h · 3 h50 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 6, with E2 and V2. What motor score M was recorded, and which response does it describe? Give the number.
GCS 6E2V2
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 87 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?
MAP 65 mmHgSBP 87 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 142 mmol/L, glucose 14.3 mmol/L and urea 10.7 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 142 mmol/Lglucose 14.3 mmol/Lurea 10.7 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 38 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 38 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
This lead II strip shows atrial flutter. Measure the flutter-wave interval and find the atrial rate in beats per minute.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
atrial rate = bpm
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 · P
Why this is the answer
AVPU stands for Alert, responds to Voice, responds to Pain, Unresponsive. A response only to a painful stimulus is "P", a serious sign that needs urgent review.
Answer
A · P
2.Nursing fundamentals
Answer: A · Refuse, as they can only sign for what they have witnessed
Why this is the answer
Countersigning means confirming that you witnessed the check and administration. Signing for something you did not see is dishonest and removes an important safety check.
Answer
A · Refuse, as they can only sign for what they have witnessed
3.Infection control & patient safety
Answer: D · Remove items that could be used for self-harm, such as belts and cords
Why this is the answer
Patients at risk of suicide need a safe environment, with belts, cords, sharp objects and glass removed, and observation at the level ordered. Privacy is secondary to safety in this situation.
Answer
D · Remove items that could be used for self-harm, such as belts and cords
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 · Check the blood glucose and ketones and contact the provider
Why this is the answer
Vomiting in type 1 diabetes can lead quickly to diabetic ketoacidosis. Glucose and ketones are checked and the provider is contacted; insulin is usually not stopped completely during illness.
Answer
C · Check the blood glucose and ketones and contact the provider
6.Prioritization & delegation
Answer: C · Sweating, shakiness and a glucose of 62 mg/dL (3.4 mmol/L) after the infusion stopped unexpectedly
Why this is the answer
Parenteral nutrition contains a lot of glucose, and the body responds with high insulin levels. If the infusion stops suddenly, rebound hypoglycemia can follow. The nurse treats the low glucose per protocol, informs the provider and follows the policy for an interrupted infusion. A modestly raised glucose, an intact dressing and a small weight change are expected or minor.
Answer
C · Sweating, shakiness and a glucose of 62 mg/dL (3.4 mmol/L) after the infusion stopped unexpectedly
7.Clinical nursing
Answer: B · To encourage deep breaths that prevent atelectasis and chest infection
Why this is the answer
Shallow breathing after surgery lets alveoli collapse, causing atelectasis and pneumonia. Deep-breathing exercises with an incentive spirometer help keep the lungs expanded.
Answer
B · To encourage deep breaths that prevent atelectasis and chest infection
8.Clinical nursing
Answer: C · To prevent accidental intravenous administration
Why this is the answer
Giving an oral or enteral medicine intravenously can be fatal. Enteral syringes with non-IV connectors, such as ENFit, make this wrong-route error much less likely.
Answer
C · To prevent accidental intravenous administration
9.Lab values & electrolytes
Answer: D · Crackles, hypertension and a raised BNP
Why this is the answer
TACO is fluid overload, often in older adults or those with heart or kidney disease. It causes dyspnea, crackles, hypertension, distended neck veins and a raised BNP. The transfusion is stopped, the patient is sat up and diuretics may be prescribed.
Answer
D · Crackles, hypertension and a raised BNP
10.Lab values & electrolytes
Answer: D · 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
D · 28 mEq/L, a high anion gap
11.Pharmacology
Answer: D · Avoid heating pads, hot baths and saunas over or near the patch
Why this is the answer
Heat increases fentanyl absorption and can cause overdose. Sites are rotated, patches are never cut, and used patches are folded sticky sides together and disposed of safely, away from children and pets.
Answer
D · Avoid heating pads, hot baths and saunas over or near the patch
12.Pharmacology
Answer: B · Digoxin
Why this is the answer
ACE inhibitors (or ARBs/ARNI), beta blockers, mineralocorticoid antagonists and SGLT2 inhibitors reduce mortality in heart failure with reduced ejection fraction. Digoxin improves symptoms and reduces admissions without reducing mortality.
Answer
B · Digoxin
13.Med-surg: cardiovascular & respiratory
Answer: C · Statins reduce further events whatever the starting cholesterol
Why this is the answer
After ACS, high-intensity statin therapy reduces recurrent MI, stroke and death regardless of baseline cholesterol, partly by stabilising plaques. It is part of standard secondary prevention with antiplatelets, beta-blockers, ACE inhibitors and lifestyle change.
Answer
C · Statins reduce further events whatever the starting cholesterol
14.Med-surg: cardiovascular & respiratory
Answer: D · Check the oxygen supply and flow so the bag stays inflated
Why this is the answer
The reservoir bag should be filled before the mask is applied and stay at least partly inflated during inspiration. A fully collapsing bag means the patient is not getting enough oxygen and may be breathing in room air. Check the supply and flow, and escalate if the patient remains hypoxic.
Answer
D · Check the oxygen supply and flow so the bag stays inflated
15.Med-surg: neuro, endocrine & renal
Answer: A · Low pH and low bicarbonate
Why this is the answer
Failing kidneys cannot excrete acid or regenerate bicarbonate, causing a metabolic acidosis with low pH and low bicarbonate. The patient may breathe faster to blow off CO2 as compensation.
Answer
A · Low pH and low bicarbonate
16.Med-surg: neuro, endocrine & renal
Answer: B · Catheter-related bloodstream infection; stop, take cultures and escalate
Why this is the answer
Fever and rigors when dialysis starts through a central catheter strongly suggest a catheter-related bloodstream infection. Dialysis is stopped or adjusted per protocol, blood cultures are taken (from the catheter and peripherally), the team is informed and IV antibiotics are started as prescribed. The exit site is inspected.
Answer
B · Catheter-related bloodstream infection; stop, take cultures and escalate
17.Med-surg: GI, perioperative & oncology
Answer: C · Bruising around the umbilicus or flanks
Why this is the answer
Cullen's sign (periumbilical bruising) and Grey Turner's sign (flank bruising) are uncommon, late signs of retroperitoneal haemorrhage in severe pancreatitis. They indicate a poor prognosis.
Answer
C · Bruising around the umbilicus or flanks
18.Med-surg: GI, perioperative & oncology
Answer: B · "I'll take my enzyme capsules at bedtime."
Why this is the answer
Pancreatic enzymes must be taken with meals and snacks to digest them. Alcohol must be avoided, steatorrhoea suggests under-replacement, and thirst or polyuria can signal diabetes from loss of islet cells.
Answer
B · "I'll take my enzyme capsules at bedtime."
19.Maternity & obstetric nursing
Answer: B · 3 compressions to 1 breath
Why this is the answer
Newborn resuscitation uses a 3:1 ratio, about 90 compressions and 30 breaths per minute, with the two-thumb technique on the lower third of the sternum.
Answer
B · 3 compressions to 1 breath
20.Maternity & obstetric nursing
Answer: D · Explain the risks and refer her for support to stop
Why this is the answer
Alcohol can harm the fetus throughout pregnancy, and stopping at any point reduces the risk. The nurse gives clear, non-judgemental information and refers her to support services.
Answer
D · Explain the risks and refer her for support to stop
21.Pediatric nursing
Answer: B · A single dose of an oral corticosteroid such as dexamethasone
Why this is the answer
Corticosteroids reduce airway swelling in croup. Nebulised epinephrine is added for severe stridor at rest. Croup is viral, so antibiotics do not help.
Answer
B · A single dose of an oral corticosteroid such as dexamethasone
22.Pediatric nursing
Answer: C · This is the temporary "honeymoon" phase; insulin is still needed
Why this is the answer
After insulin treatment starts, remaining beta cells may recover partly, so insulin needs fall for weeks to months. This partial remission is temporary; insulin should continue, with doses adjusted to glucose readings.
Answer
C · This is the temporary "honeymoon" phase; insulin is still needed
23.Mental health nursing
Answer: C · Ibuprofen
Why this is the answer
NSAIDs, thiazide diuretics and ACE inhibitors reduce lithium clearance and can cause toxicity. Paracetamol is usually preferred for mild pain in patients on lithium.
Answer
C · Ibuprofen
24.Mental health nursing
Answer: D · Probable delirium: look for an underlying physical cause and inform the team
Why this is the answer
Acute, fluctuating confusion suggests delirium, often caused by infection, pain, drugs, dehydration, urinary retention or hypoxia. It is a medical emergency; the cause is treated and the patient is kept safe with non-drug measures first.
Answer
D · Probable delirium: look for an underlying physical cause and inform the team
25.Nursing math & unit conversions
Answer: 23:20
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Convert the hour
11 PM → 11 + 12 = 23
Answer
23:20
Answer
23:20
26.Nursing math & unit conversions
Answer: t = 8.33 h
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
20:35 → 24:00 = 205 min
After midnight
00:00 → 04:55 = 295 min
Total
205 + 295 = 500 min
t = 500/60 = 8.333 ≈ 8.33 h
Answer
t = 8.33 h
27.Dosage calculations
Answer: V = 0.5 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.
Concentration
1:1000 = 1 g/1000 mL = 1 mg/mL
Volume
V = 0.5/1 = 0.5 mL
Answer
V = 0.5 mL
US labels now state mg/mL (1 mg/mL = 1:1000; 0.1 mg/mL = 1:10 000). Never give 1 mg/mL epinephrine IV push.
28.Dosage calculations
Answer: R = 30 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
40000/1000 = 40 units/mL
Pump rate
R = 1200/40 = 30 mL/h
Answer
R = 30 mL/h
29.IV infusion rates
Answer: R = 100 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 = 1500·20/300 = 100 gtt/min
Answer
R = 100 gtt/min
30.IV infusion rates
Answer: D = 200 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
400/50 = 8 mg/mL
Dose rate
D = 8·25 = 200 mg/h
Answer
D = 200 mg/h
31.Pediatric & critical-care dosing
Answer: R = 2.5 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.
Concentration
100/250 = 0.4 units/mL
Pump rate
R = 1/0.4 = 2.5 mL/h
Answer
R = 2.5 mL/h
32.Pediatric & critical-care dosing
Answer: R = 17.4 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
5·58 = 290 mcg/min
290·60 = 17400 mcg/h
Pump rate
R = 17400/1000 = 17.4 mL/h
Answer
R = 17.4 mL/h
33.IV fluids & fluid balance
Answer: B = 980 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 + 180 = 400 mL
ice chips: 240/2 = 120 mL
IV infusion: 80·12 = 960 mL
IV antibiotic: 2·50 = 100 mL
total intake = 1580 mL
Total output
425 + 175 = 600 mL
Balance
B = 1580 − 600 = 980 mL
Answer
B = 980 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 8.2 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.
First part
80·3 = 240 mL
500 − 240 = 260 mL left
Second part
260/50 = 5.2 h
Total time
t = 3 + 5.2 = 8.2 h
Answer
t = 8.2 h
That is about 8 h 12 min, so the bag runs out at about 21:12.
35.Clinical assessment scores
Answer: M = 2
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Motor score
M = 6 − 2 − 2 = 2
M2: extension of the arms and legs (abnormal extension)
Answer
M = 2
36.Clinical assessment scores
Answer: DBP = 54 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·65 − 87)/2 = 108/2 = 54 mmHg
Answer
DBP = 54 mmHg
37.Arterial blood gas interpretation
Answer: Osm = 309 mOsm/kg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Calculated osmolality
Osm = 2·142 + 14.3 + 10.7 = 309 ≈ 309 mOsm/kg
Answer
Osm = 309 mOsm/kg
38.Arterial blood gas interpretation
Answer: PaCO₂ = 47.6 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
0.7·38 + 21 = 47.6 mmHg
Answer
PaCO₂ = 47.6 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: atrial rate = 300 bpm
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.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 per minute
conduction ratio = 300 ÷ 75 = 4:1
Answer
atrial rate = 300 bpm
40.ECG rhythm strip interpretation
Answer: ventricular rate = 58 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 = 17 small boxes = 0.68 s → 1500 ÷ 17 = 88.24 ≈ 88 per minute
Ventricular rate
R–R = 26 small boxes = 1.04 s → 1500 ÷ 26 = 57.69 ≈ 58 per minute
Answer
ventricular rate = 58 bpm
Answer
ventricular rate = 58 bpm
Third-degree block with a narrow-complex junctional escape (usually 40–60 per minute).
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