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
What does the Malnutrition Universal Screening Tool (MUST) assess?
ASwallowing ability
BThe level of pain
CThe risk of falling
DThe risk of malnutrition
2.Nursing fundamentalsHard
Which task is most appropriate for a registered nurse to delegate to a healthcare assistant (nursing assistant)?
AAssessing a newly admitted patient's falls risk
BHelping a stable patient walk to the bathroom
CTeaching a patient how to use crutches
DEvaluating a patient who has just fallen
3.Infection control & patient safetyMedium
A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?
AA vest restraint applied for the whole night
BFour side rails raised and the door closed so the patient stays in bed
CA sedative given every few hours as needed
DA trained sitter or video monitoring with staff nearby
4.Infection control & patient safetyHard
A competent patient at high risk of falls insists on walking to the bathroom alone. What is the best nursing approach?
ARemove the patient’s shoes and walking aid so that they cannot walk alone
BExplain the risks, agree on ways to reduce them, respect the decision and document
CApply wrist restraints so the patient stays in bed
DTell the patient that walking alone is against hospital law
5.Prioritization & delegationMedium
A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?
ACheck the tubing for kinks or obstruction
BRemove the catheter and wait for the patient to void
CEncourage the patient to drink more water
DGive a prescribed diuretic straight away
6.Prioritization & delegationHard
A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?
AWrapping the runner in a blanket to prevent shivering
BAsking the runner to rest in the shade and drink slowly
CGiving an antipyretic tablet and waiting for it to work
DRapid cooling while supporting airway and circulation
7.Clinical nursingMedium
After a total hip replacement through a posterior approach, which movement should the patient usually avoid in the early weeks?
AWalking short distances with a frame and a physiotherapist
BLying on their back
CBending the hip beyond 90 degrees or crossing the legs
DDoing gentle ankle exercises
8.Clinical nursingHard
A patient on an unfractionated heparin infusion is also started on warfarin. Which tests are used to monitor each drug?
AD-dimer for both drugs
BINR for heparin and APTT for warfarin
CAPTT for heparin and INR for warfarin
DPlatelet count for both drugs
9.Lab values & electrolytesMedium
A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?
AInform the provider and arrange a new, correctly collected sample
BRecord the result as a confirmed urinary tract infection
CStart treatment for all three organisms with three antibiotics
DDiscard the report, because a mixed growth is always normal
10.Lab values & electrolytesHard
A patient with a stable INR on warfarin starts rifampin (rifampicin) for tuberculosis. Two weeks later the INR is 1.3. What is the most likely explanation?
ARifampin raises the INR, so it is wrong
BRifampin contains a lot of vitamin K
CRifampin speeds up warfarin metabolism
DTuberculosis causes the INR to fall
11.PharmacologyMedium
A patient takes regular paracetamol (acetaminophen) at home. Which teaching point best prevents accidental overdose?
AUse paracetamol only on an empty stomach
BTake paracetamol with alcohol to improve absorption
CTake an extra dose if the first one does not work within 10 minutes
DCheck cold and flu remedies, as many also contain paracetamol
12.PharmacologyHard
A breastfeeding mother needs a mild analgesic. Which drug is generally considered compatible with breastfeeding?
ACodeine (as co-codamol)
BParacetamol (acetaminophen)
CAspirin
DPethidine (meperidine)
13.Med-surg: cardiovascular & respiratoryMedium
A patient taking isosorbide mononitrate asks about sildenafil for erectile dysfunction. What is the main danger?
AA very high potassium level
BSevere hypertension
CBleeding from the gums
DSevere hypotension
14.Med-surg: cardiovascular & respiratoryHard
A patient with squamous cell lung cancer becomes confused, thirsty and constipated, with abdominal pain. Which electrolyte disturbance is most likely?
AHypomagnesaemia
BHyponatraemia
CHypercalcaemia
DHypokalaemia
15.Med-surg: neuro, endocrine & renalMedium
Why do patients with CKD often take phosphate binders with meals?
AThey lower blood potassium by binding it in the gut
BThey increase the absorption of phosphate from food in the gut
CThey replace the missing hormone erythropoietin
DThey bind food phosphate that the kidneys cannot excrete
16.Med-surg: neuro, endocrine & renalHard
After a stroke, a patient suddenly cries or laughs at odd moments. They say they do not feel sad. Which response is most appropriate?
AIgnore it, because it shows that the patient is seeking attention from the staff
BAsk the doctor for a sedative to stop the outbursts
CTell the patient that crying will slow their recovery
DExplain that this is emotional lability after stroke and help the family understand
17.Med-surg: GI, perioperative & oncologyMedium
What is the main treatment for a venous leg ulcer with an adequate arterial supply?
AStrong oral antibiotics for all ulcers
BCompression therapy
CSurgery to amputate the limb
DKeeping the leg hanging down all day
18.Med-surg: GI, perioperative & oncologyHard
In week 5 of radiotherapy, the skin in the treatment field is broken, moist and painful. What should the nurse do?
AApply adhesive tape directly over the area to protect it from clothing
BUse a heat pad to speed healing
CReport it, keep it clean and use a non-adherent dressing
DScrub the area with soap to prevent infection
19.Maternity & obstetric nursingMedium
Which baseline variability is considered moderate (normal)?
AAn amplitude of 0 to 2 bpm
BAn amplitude of more than 25 bpm
CAn amplitude of 3 to 5 bpm
DAn amplitude of 6 to 25 bpm
20.Maternity & obstetric nursingHard
A newborn's bilirubin is rising quickly at 30 hours despite phototherapy, and the baby is lethargic with an arched back and high-pitched cry. What does this suggest?
AAcute bilirubin encephalopathy
BMild breast milk jaundice
CA normal reaction to phototherapy
DNormal newborn reflexes
21.Pediatric nursingMedium
Which group of findings suggests Kawasaki disease?
ALow-grade fever, a barking cough and stridor that are worse at night
BFever with an itchy vesicular rash that starts on the trunk, spreads outwards and crusts over within days
CFever for at least 5 days, red eyes without discharge, cracked red lips and swollen hands and feet
DHigh fever for 3 days, then a pink rash as the fever settles
22.Pediatric nursingHard
Which finding in a 3-month-old with bronchiolitis requires immediate follow-up?
AA runny nose and mild cough
BWheeze heard on auscultation
CFeeding slightly less than usual but still with wet nappies
DPauses in breathing (apnoea) and an oxygen saturation of 88%
23.Mental health nursingMedium
A patient in a manic episode makes repeated sexual comments to a nurse. What is the most appropriate response?
ARespond with similar comments to build rapport
BAvoid the patient for the rest of the shift
CCalmly say that the comments are not acceptable and redirect him
DLaugh at the comments so he does not feel rejected
24.Mental health nursingHard
A patient is pacing, has clenched fists and is shouting at staff. What is the most appropriate first approach?
AStand close to the patient and raise your voice so that you clearly take control of the situation
BUse calm verbal de-escalation, keep a safe distance and make sure both of you have an exit
CRestrain the patient immediately
DTurn your back and ignore the behaviour
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for an injection gives 3.3898 mL. The rule in this exercise is that volumes of 1 mL or more are rounded to the nearest tenth of a mL. What value x do you record?
3.3898 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An order reads 5 mcg/kg/min for a patient who weighs 58 kg. Express the dose rate D in mg/h. Round to two decimal places.
5 mcg/kg/min58 kg
D = mg/h
27.Dosage calculationsMedium
A dose of 100 mg is needed from a 5% (w/v) solution. What volume V contains this dose?
100 mg5% w/v
V = mL
28.Dosage calculationsHard
The prescription is 3300 units of a drug that comes as 5000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
3300 units5000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 500 mL over 2 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL2 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 32 gtt/min through a set of 60 gtt/mL. There are 750 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
32 gtt/min60 gtt/mL750 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 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.
20 000 units/500 mL15 units/kg/h62 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 57 kg has an order for nitroglycerin at 30 mcg/min. The bag contains 50 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
50 mg/250 mL30 mcg/min57 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 8-hour shift. The patient weighs 102 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 13:00 and runs by pump at 120 mL/h. How many mL V are left in the bag at 14:30?
500 mL120 mL/h13:00 → 14:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 9, with E2 and V3. What motor score M was recorded, and which response does it describe? Give the number.
GCS 9E2V3
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: no; ambulatory aid: holds on to furniture; IV therapy or saline lock: no; gait: normal, bed rest or wheelchair; mental status: overestimates or forgets limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.55, PaCO₂ 47 mmHg (6.3 kPa) and HCO₃⁻ 40 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.55PaCO₂ 47 mmHg (6.3 kPa)HCO₃⁻ 40 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 136, Cl⁻ 93 and HCO₃⁻ 14 mmol/L. Calculate the delta ratio (AG − 12)/(24 − HCO₃⁻), using AG = Na⁺ − (Cl⁻ + HCO₃⁻). Give two decimals.
Na⁺ 136 mmol/LCl⁻ 93 mmol/LHCO₃⁻ 14 mmol/L
delta ratio =
39.ECG rhythm strip interpretationMedium
This lead II strip shows atrial flutter. How many flutter waves per QRS complex are there (the n of n:1 conduction)?
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
flutter waves per QRS =
40.ECG rhythm strip interpretationHard
Identify the rhythm on this lead II strip. 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
1ventricular tachycardia
2atrial flutter, 2:1 conduction
3supraventricular tachycardia (SVT)
4torsades de pointes
3Solutions
1.Nursing fundamentals
Answer: D · The risk of malnutrition
Why this is the answer
MUST combines body mass index, unplanned weight loss and acute disease effect into a score that shows the risk of malnutrition and guides nutritional care.
Answer
D · The risk of malnutrition
2.Nursing fundamentals
Answer: B · Helping a stable patient walk to the bathroom
Why this is the answer
Routine help with care for a stable patient can be delegated. Assessment, teaching and evaluation need registered nurse judgement.
Answer
B · Helping a stable patient walk to the bathroom
3.Infection control & patient safety
Answer: D · A trained sitter or video monitoring with staff nearby
Why this is the answer
Close observation by a sitter or video monitoring allows staff to step in quickly, without restricting the patient. It is often combined with reorientation and family presence.
Answer
D · A trained sitter or video monitoring with staff nearby
4.Infection control & patient safety
Answer: B · Explain the risks, agree on ways to reduce them, respect the decision and document
Why this is the answer
A competent patient can accept a risk. The nurse explains the danger, offers measures such as a low bed, non-slip footwear, a clear path and a call light, respects the choice and documents the discussion.
Answer
B · Explain the risks, agree on ways to reduce them, respect the decision and document
5.Prioritization & delegation
Answer: A · Check the tubing for kinks or obstruction
Why this is the answer
Sudden lack of drainage with a full bladder usually means a kinked or blocked catheter. The nurse checks the tubing and position first, then follows the policy for irrigation or replacement.
Answer
A · Check the tubing for kinks or obstruction
6.Prioritization & delegation
Answer: D · Rapid cooling while supporting airway and circulation
Why this is the answer
Heat stroke is an emergency in which body temperature rises and the brain is affected. Rapid cooling, for example with cold water or ice, is the priority; antipyretics do not work for heat stroke.
Answer
D · Rapid cooling while supporting airway and circulation
7.Clinical nursing
Answer: C · Bending the hip beyond 90 degrees or crossing the legs
Why this is the answer
Hip flexion past 90°, crossing the legs and turning the leg inwards can dislocate the hip after a posterior approach. Raised seats and toilet seats help, although specific precautions vary between units.
Answer
C · Bending the hip beyond 90 degrees or crossing the legs
8.Clinical nursing
Answer: C · APTT for heparin and INR for warfarin
Why this is the answer
The APTT reflects the intrinsic pathway and is used to adjust heparin infusions. Warfarin is monitored by the INR, a standardised prothrombin time. Platelets are also checked on heparin to detect HIT.
Answer
C · APTT for heparin and INR for warfarin
9.Lab values & electrolytes
Answer: A · Inform the provider and arrange a new, correctly collected sample
Why this is the answer
Several organisms in one urine sample usually mean contamination from the skin or perineum during collection. The provider is informed, and a new clean-catch or catheter-port sample is usually needed before an infection can be confirmed.
Answer
A · Inform the provider and arrange a new, correctly collected sample
10.Lab values & electrolytes
Answer: C · Rifampin speeds up warfarin metabolism
Why this is the answer
Rifampin induces liver enzymes that break down warfarin, so warfarin's effect falls and the INR drops, increasing clot risk. The INR is monitored closely and the dose adjusted; the reverse happens when rifampin is stopped.
Answer
C · Rifampin speeds up warfarin metabolism
11.Pharmacology
Answer: D · Check cold and flu remedies, as many also contain paracetamol
Why this is the answer
Many combination products contain paracetamol, so a patient can take too much without realising. Regular alcohol use and liver disease also increase the risk of liver damage.
Answer
D · Check cold and flu remedies, as many also contain paracetamol
12.Pharmacology
Answer: B · Paracetamol (acetaminophen)
Why this is the answer
Paracetamol passes into milk in small amounts and is widely regarded as safe. Codeine can cause dangerous opioid levels in babies of ultra-rapid metaboliser mothers, aspirin carries a Reye's risk and pethidine's metabolite accumulates in infants.
Answer
B · Paracetamol (acetaminophen)
13.Med-surg: cardiovascular & respiratory
Answer: D · Severe hypotension
Why this is the answer
Phosphodiesterase-5 inhibitors such as sildenafil enhance the vasodilator effect of nitrates and can cause profound, life-threatening hypotension. The combination is contraindicated, and patients should tell emergency staff if they have taken one.
Answer
D · Severe hypotension
14.Med-surg: cardiovascular & respiratory
Answer: C · Hypercalcaemia
Why this is the answer
Squamous cell lung cancer can secrete PTH-related protein, and bone metastases can release calcium. Hypercalcaemia causes confusion, thirst, polyuria, constipation, abdominal pain and arrhythmias ("bones, stones, groans and psychiatric overtones"). Treatment includes IV fluids and bisphosphonates.
Answer
C · Hypercalcaemia
15.Med-surg: neuro, endocrine & renal
Answer: D · They bind food phosphate that the kidneys cannot excrete
Why this is the answer
In CKD, phosphate retention leads to secondary hyperparathyroidism, renal bone disease and vascular calcification. Phosphate binders taken with meals bind dietary phosphate in the gut. Dietary phosphate is also limited.
Answer
D · They bind food phosphate that the kidneys cannot excrete
16.Med-surg: neuro, endocrine & renal
Answer: D · Explain that this is emotional lability after stroke and help the family understand
Why this is the answer
Emotional lability (pseudobulbar affect) is common after stroke: crying or laughter does not match the person's mood. Explaining it, staying calm and gently distracting the patient helps. True depression is also common and should be screened for separately.
Answer
D · Explain that this is emotional lability after stroke and help the family understand
17.Med-surg: GI, perioperative & oncology
Answer: B · Compression therapy
Why this is the answer
Graduated compression reduces venous hypertension and oedema and speeds healing. Leg elevation, exercise and treating the underlying vein disease also help.
Answer
B · Compression therapy
18.Med-surg: GI, perioperative & oncology
Answer: C · Report it, keep it clean and use a non-adherent dressing
Why this is the answer
Moist desquamation is a more severe radiation skin reaction. The radiotherapy team is informed; the area is kept clean and covered with non-adherent dressings, avoiding adhesive on the skin, and analgesia is given. Infection is watched for.
Answer
C · Report it, keep it clean and use a non-adherent dressing
19.Maternity & obstetric nursing
Answer: D · An amplitude of 6 to 25 bpm
Why this is the answer
Moderate variability (6–25 bpm) shows an oxygenated fetus with a functioning autonomic nervous system. Minimal (5 bpm or less) or absent variability can mean hypoxia, sleep or medication effects; more than 25 bpm is marked variability.
Answer
D · An amplitude of 6 to 25 bpm
20.Maternity & obstetric nursing
Answer: A · Acute bilirubin encephalopathy
Why this is the answer
Lethargy, poor feeding, hypertonia with arching and a high-pitched cry are signs of acute bilirubin encephalopathy. An urgent exchange transfusion may be needed to prevent permanent kernicterus.
Answer
A · Acute bilirubin encephalopathy
21.Pediatric nursing
Answer: C · Fever for at least 5 days, red eyes without discharge, cracked red lips and swollen hands and feet
Why this is the answer
Kawasaki disease causes persistent fever plus features such as non-purulent conjunctivitis, red cracked lips and strawberry tongue, rash, swollen hands and feet and enlarged neck lymph nodes. The other options describe croup, chickenpox and roseola.
Answer
C · Fever for at least 5 days, red eyes without discharge, cracked red lips and swollen hands and feet
22.Pediatric nursing
Answer: D · Pauses in breathing (apnoea) and an oxygen saturation of 88%
Why this is the answer
Apnoea and low oxygen saturation are signs of severe bronchiolitis and need urgent assessment and support. The other findings are typical of mild bronchiolitis.
Answer
D · Pauses in breathing (apnoea) and an oxygen saturation of 88%
23.Mental health nursing
Answer: C · Calmly say that the comments are not acceptable and redirect him
Why this is the answer
Disinhibition is common in mania. Clear, calm limit setting and redirection protect both staff and patient and maintain boundaries without punishing him.
Answer
C · Calmly say that the comments are not acceptable and redirect him
24.Mental health nursing
Answer: B · Use calm verbal de-escalation, keep a safe distance and make sure both of you have an exit
Why this is the answer
De-escalation uses a calm voice, simple language, active listening and offering choices, while keeping a safe distance and an exit route. Restraint is a last resort if there is imminent danger.
Answer
B · Use calm verbal de-escalation, keep a safe distance and make sure both of you have an exit
25.Nursing math & unit conversions
Answer: x = 3.4 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the tenths place
3.3898 → 3
Only the next digit decides
3.3898 → 8
8 is 5 or more, so round 3 up.
The digits after it (98) are ignored: round once, never step by step.
Round
x = 3.4 mL
Answer
x = 3.4 mL
26.Nursing math & unit conversions
Answer: D = 17.4 mg/h
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 5 mcg/kg/min × 58 kg × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 5·58·60/1000 = 17.4 mg/h
Answer
D = 17.4 mg/h
27.Dosage calculations
Answer: V = 2 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
5% = 50 mg/mL
Volume
V = 100/50 = 2 mL
Answer
V = 2 mL
28.Dosage calculations
Answer: V = 0.66 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 3300/5000 = 0.66 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.66 mL
29.IV infusion rates
Answer: R = 83 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
2·60 = 120 min
Drip rate
R = 500·20/120 = 83.33 ≈ 83 gtt/min
Answer
R = 83 gtt/min
At the bedside you round to the nearest whole drop: 83 gtt/min.
30.IV infusion rates
Answer: t = 23.4 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.
Rate in mL/h
32·60/60 = 32 mL/h
Time left
t = 750/32 = 23.44 ≈ 23.4 h
Answer
t = 23.4 h
31.Pediatric & critical-care dosing
Answer: R = 23.3 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
20 000/500 = 40 units/mL
Pump rate
R = 930/40 = 23.25 ≈ 23.3 mL/h
Answer
R = 23.3 mL/h
32.Pediatric & critical-care dosing
Answer: R = 9 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
50 000/250 = 200 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
30·60 = 1800 mcg/h
Pump rate
R = 1800/200 = 9 mL/h
Answer
R = 9 mL/h
33.IV fluids & fluid balance
Answer: U = 1.29 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
175 + 150 + 300 + 425 = 1050 mL
Per kilogram per hour
U = 1050/(102·8) = 1.287 ≈ 1.29 mL/kg/h
Answer
U = 1.29 mL/kg/h
34.IV fluids & fluid balance
Answer: V = 320 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
13:00 → 14:30 = 1.5 h
Volume infused
120·1.5 = 180 mL
Volume left
V = 500 − 180 = 320 mL
Answer
V = 320 mL
35.Clinical assessment scores
Answer: M = 4
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 = 9 − 2 − 3 = 4
M4: withdraws the limb from pressure (normal flexion)
Answer
M = 4
36.Clinical assessment scores
Answer: high risk
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: no → 0
secondary diagnosis: no → 0
ambulatory aid: holds on to furniture → 30
IV therapy or saline lock: no → 0
gait: normal, bed rest or wheelchair → 0
mental status: overestimates or forgets limits → 15
Add
Morse total = 0 + 0 + 30 + 0 + 0 + 15 = 45
Risk level
45 → high risk
Answer
high risk
37.Arterial blood gas interpretation
Answer: partially compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.55: alkalaemia (above 7.45)
PaCO₂ 47 mmHg: high (35–45)
HCO₃⁻ 40 mmol/L: high (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: delta ratio = 1.7
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 = 136 − (93 + 14) = 29
Delta ratio
(29 − 12)/(24 − 14) = 17/10 = 1.7
Answer
delta ratio = 1.7
Between 1 and 2: a pure high anion gap acidosis.
39.ECG rhythm strip interpretation
Answer: flutter waves per QRS = 4
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
flutter waves per QRS = 4
40.ECG rhythm strip interpretation
Answer: ventricular tachycardia
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
Five steps
1. Rate: R–R = 10 small boxes, 1500 ÷ 10 ≈ 150 per minute.
2. Rhythm: regular, every R–R is 0.40 s.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: 0.14 s, wide (0.12 s or more).
Interpretation
ventricular tachycardia
Answer
ventricular tachycardia
In resuscitation guidelines VF and pulseless VT are the shockable rhythms. This is identification practice only.
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