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 is the main aim of "protected mealtimes" on hospital wards?
ATo give staff a fixed break while the patients are eating their meals
BTo stop visitors from bringing any food into hospital
CTo let patients eat without interruptions, with help where needed
DTo make sure all patients eat the same meal at once
2.Nursing fundamentalsHard
Which task is most appropriate for a registered nurse to delegate to a healthcare assistant (nursing assistant)?
AHelping a stable patient walk to the bathroom
BTeaching a patient how to use crutches
CAssessing a newly admitted patient's falls risk
DEvaluating a patient who has just fallen
3.Infection control & patient safetyMedium
A patient is receiving opioids for pain. Which sign usually comes before opioid-induced respiratory depression?
ADiarrhea
BDilated pupils
CIncreasing sedation
DRising blood pressure
4.Infection control & patient safetyHard
A nurse teaches parents about using an infant car seat. Which statement shows a need for further teaching?
A“We will install the seat in the back seat, facing the rear.”
B“We will put the rear-facing seat in the front so we can see the baby.”
C“We will use the car seat for every trip, even short ones.”
D“We will make sure the harness straps are snug against the baby’s chest.”
5.Prioritization & delegationMedium
Which patient can the nurse safely see last?
AA patient with new crackles and pink, frothy sputum
BA patient with a sudden severe headache
CA patient with COPD on 1 L/min oxygen, SpO₂ 90% (target 88–92%), talking in full sentences
DA patient two hours after surgery with a heart rate rising from 88 to 118/min
6.Prioritization & delegationHard
A patient on peritoneal dialysis has cloudy fluid draining out and abdominal pain. What does this most likely mean?
AA normal finding at the end of each exchange
BPeritonitis, which needs prompt reporting and a fluid sample
CConstipation that will settle with a laxative later today or tomorrow
DToo much fluid left in the abdomen after the drain
7.Clinical nursingMedium
Why does a patient with a suspected TIA need urgent specialist assessment?
AThe patient needs urgent surgery on the brain
BA TIA always turns into a brain tumour unless it is treated
CThe symptoms will come back permanently within an hour
DThe risk of a full stroke is highest in the days after a TIA
8.Clinical nursingHard
Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?
AEnteral syringes keep the medicine sterile
BTo prevent accidental intravenous administration
CIV syringes cannot hold liquid medicines
DEnteral syringes measure doses less accurately
9.Lab values & electrolytesMedium
A patient with HIV on antiretroviral therapy has an undetectable viral load. What does this mean?
AThe treatment is suppressing the virus very well
BThe virus has been completely cured and removed
CThe CD4 count must now be dangerously low too
DThe treatment can now be stopped without any risk
10.Lab values & electrolytesHard
A patient with a sodium of 132 mEq/L and blood glucose of 600 mg/dL (33.3 mmol/L) is admitted. Why is the sodium value interpreted with care?
AThe sodium result must be a laboratory error
BHigh glucose raises the measured sodium falsely, so it is really lower
CGlucose has no effect on the measured sodium
DHigh glucose draws water into the blood, diluting the sodium
11.PharmacologyMedium
A patient must mix regular (soluble) insulin and NPH (isophane) insulin in one syringe. What is the correct order?
ADraw up the clear regular insulin first, then the cloudy NPH insulin
BDraw them up in separate syringes, then mix them in a cup
CDraw up the cloudy NPH insulin first, then the clear regular insulin
DShake both vials hard, then draw them up in any order
12.PharmacologyHard
Codeine is converted to morphine by CYP2D6. What happens in a patient who is a CYP2D6 ultra-rapid metaboliser?
AMore morphine is formed, increasing the risk of opioid toxicity
BCodeine is converted to an inactive compound only
CCodeine gives almost no pain relief because little morphine is formed
DCodeine is excreted unchanged in the urine
13.Med-surg: cardiovascular & respiratoryMedium
Why are patients with severe COPD encouraged to eat small, frequent meals?
AFrequent meals prevent chest infections directly
BLarge meals cause the airways to narrow permanently
CSmall meals reduce how often the inhalers are needed
DA full stomach limits the diaphragm and eating is tiring
14.Med-surg: cardiovascular & respiratoryHard
A patient with life-threatening asthma has not responded to repeated nebulised salbutamol (albuterol), ipratropium and steroids. Which drug is commonly given intravenously next?
AMagnesium sulfate
BIntravenous furosemide
CMorphine
DMetoprolol
15.Med-surg: neuro, endocrine & renalMedium
Which picture fits Brown-Séquard syndrome?
ALoss of all feeling but normal movement on both sides
BParalysis of both legs, with normal sensation everywhere in the body
CWeakness on the same side and loss of pain on the opposite side
DWeakness of both arms with normal strength in the legs
16.Med-surg: neuro, endocrine & renalHard
Weeks after starting insulin, a patient with newly diagnosed type 1 diabetes needs much less insulin and has frequent mild hypos. What is the most likely explanation?
AThe patient actually has type 2 diabetes
BThe insulin has gone off and should be replaced
CA honeymoon phase, but insulin is still needed
DThe diabetes has been cured, so insulin can stop
17.Med-surg: GI, perioperative & oncologyMedium
Why is it important to prevent perioperative hypothermia?
AIt makes patients wake up from the anaesthetic too quickly
BIt lowers the risk of pain after surgery
CIt reduces the amount of anaesthetic needed, which is unsafe
DIt increases bleeding, wound infection and heart complications
18.Med-surg: GI, perioperative & oncologyHard
Which safety rule applies to vincristine?
ANever intrathecal; supplied in a minibag for IV use only
BIt can be given by whichever route the prescriber prefers
CIt is best given as a fast IV push into a small vein
DIt is usually given intrathecally with other spinal drugs
19.Maternity & obstetric nursingMedium
A pregnant woman takes warfarin for a mechanical heart valve. Why is she usually switched to heparin for much of the pregnancy?
AWarfarin is ineffective in pregnancy
BHeparin crosses the placenta better and also protects the fetus
CWarfarin crosses the placenta and can harm the fetus
DHeparin can be taken as a tablet once a day
20.Maternity & obstetric nursingHard
A newborn has a deep dimple with a tuft of hair over the lower spine. What is the significance?
AIt is a sign of congenital heart disease
BIt may be a sign of an underlying spinal defect
CIt is an expected birthmark with no meaning
DIt means the baby will have hip dysplasia
21.Pediatric nursingMedium
Using the 100–50–20 rule, what is the daily maintenance fluid requirement for a 15 kg child?
A1500 mL per day
B750 mL per day
C1250 mL per day
D1000 mL per day
22.Pediatric nursingHard
A child develops the "slapped cheek" rash of fifth disease. The parent asks whether the child is still infectious. What is the best answer?
AYes, for 6 weeks after the rash appears
BThe illness is not infectious at any stage
CUsually not; the child was most infectious before the rash appeared
DYes, until every trace of the rash has faded from the cheeks and limbs
23.Mental health nursingMedium
A patient who drinks heavily every day was admitted this morning. When do early signs of alcohol withdrawal, such as tremor, sweating and anxiety, usually begin?
AAbout 2–3 weeks after the last drink
BOnly after 7 days without alcohol
CWithin 5 minutes of the last drink
DAbout 6–24 hours after the last drink
24.Mental health nursingHard
A patient asks, "Do you think I should divorce my husband?" Which response best supports the patient's autonomy?
A"What are your thoughts about the options you have?"
B"No, divorce would only make things worse for you."
C"Yes, I think you'd be happier without him."
D"You should ask your doctor what to do about it."
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 96.1 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
96.1 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 21:30 and finishes at 09:00 the next morning (24-hour clock). How many minutes t did it run?
21:3009:00
t = min
27.Dosage calculationsMedium
A child weighing 16 kg is prescribed 2.5 mg/kg of a drug. The stock solution contains 10 mg/mL. Draw up the dose: what volume V do you give?
16 kg2.5 mg/kg10 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 4400 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?
4400 units5000 units/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 50 gtt/min through a set of 20 gtt/mL. How many millilitres V does the patient receive in 3 hours?
50 gtt/min20 gtt/mL3 h
V = mL
30.IV infusion ratesHard
An infusion of 50 mg in 500 mL runs at 12 mL/h. How many micrograms per minute D does the patient receive?
50 mg/500 mL12 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 15 units/kg/h for a patient who weighs 108 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/h108 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 500 mg in 250 mL. The order is 2.5 mcg/kg/min for a patient who weighs 69 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
500 mg/250 mL2.5 mcg/kg/min69 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 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 runs by pump at 75 mL/h. At 10:30, 250 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL250 mL infused75 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: no impairment; moisture: very moist; activity: walks frequently; mobility: completely immobile; nutrition: probably inadequate; friction and shear: no apparent problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 47 kg and is 162 cm tall. Calculate the BMI and click the WHO weight category.
47 kg162 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 138 mmol/L, glucose 18.2 mmol/L and urea 9.1 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 138 mmol/Lglucose 18.2 mmol/Lurea 9.1 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows pH 7.32, PaCO₂ 34 mmHg (4.5 kPa) and HCO₃⁻ 17 mmol/L, with Na⁺ 139 and Cl⁻ 98 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Bazett’s formula QTc = QT/√RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
A patient without a palpable pulse has this organised rhythm on the monitor (pulseless electrical activity). Which treatment do adult resuscitation guidelines name for 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
1transcutaneous pacing
2synchronised cardioversion
3CPR (non-shockable rhythm)
4immediate defibrillation
3Solutions
1.Nursing fundamentals
Answer: C · To let patients eat without interruptions, with help where needed
Why this is the answer
Ward rounds and tests can interrupt meals, and patients then eat less. Protected mealtimes pause non-urgent activity so staff can focus on helping patients eat.
Answer
C · To let patients eat without interruptions, with help where needed
2.Nursing fundamentals
Answer: A · 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
A · Helping a stable patient walk to the bathroom
3.Infection control & patient safety
Answer: C · Increasing sedation
Why this is the answer
Sedation increases before respiratory depression occurs, so sedation levels are checked regularly along with breathing. A patient who is getting harder to wake needs the opioid held and the prescriber informed.
Answer
C · Increasing sedation
4.Infection control & patient safety
Answer: B · “We will put the rear-facing seat in the front so we can see the baby.”
Why this is the answer
A rear-facing car seat must never be placed in front of an active airbag, which can strike the seat with great force. Infants ride rear-facing in the back seat, with a snug harness, on every trip.
Answer
B · “We will put the rear-facing seat in the front so we can see the baby.”
5.Prioritization & delegation
Answer: C · A patient with COPD on 1 L/min oxygen, SpO₂ 90% (target 88–92%), talking in full sentences
Why this is the answer
The COPD patient is within the prescribed target and is comfortable, so this patient is stable. A rising heart rate after surgery, signs of pulmonary edema and a sudden severe headache all need prompt assessment.
Answer
C · A patient with COPD on 1 L/min oxygen, SpO₂ 90% (target 88–92%), talking in full sentences
6.Prioritization & delegation
Answer: B · Peritonitis, which needs prompt reporting and a fluid sample
Why this is the answer
Cloudy effluent with abdominal pain is a classic sign of peritonitis, a serious complication of peritoneal dialysis. The nurse reports it and sends a sample as prescribed so antibiotics can start.
Answer
B · Peritonitis, which needs prompt reporting and a fluid sample
7.Clinical nursing
Answer: D · The risk of a full stroke is highest in the days after a TIA
Why this is the answer
The risk of stroke is highest soon after a TIA. Rapid assessment and treatment, such as antiplatelets, statins and carotid imaging, reduce this risk.
Answer
D · The risk of a full stroke is highest in the days after a TIA
8.Clinical nursing
Answer: B · 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
B · To prevent accidental intravenous administration
9.Lab values & electrolytes
Answer: A · The treatment is suppressing the virus very well
Why this is the answer
An undetectable viral load shows that antiretroviral therapy is suppressing viral replication. The virus remains in the body, so treatment must continue. People with a sustained undetectable viral load do not transmit HIV sexually.
Answer
A · The treatment is suppressing the virus very well
10.Lab values & electrolytes
Answer: D · High glucose draws water into the blood, diluting the sodium
Why this is the answer
High glucose draws water from the cells into the blood, lowering the measured sodium. As the glucose is treated, the sodium usually rises. A common correction adds about 1.6–2.4 mEq/L of sodium for every 100 mg/dL of glucose above 100 mg/dL.
Answer
D · High glucose draws water into the blood, diluting the sodium
11.Pharmacology
Answer: A · Draw up the clear regular insulin first, then the cloudy NPH insulin
Why this is the answer
Drawing up regular insulin first prevents NPH from contaminating the regular insulin vial. NPH is gently rolled, not shaken, to mix it.
Answer
A · Draw up the clear regular insulin first, then the cloudy NPH insulin
12.Pharmacology
Answer: A · More morphine is formed, increasing the risk of opioid toxicity
Why this is the answer
Ultra-rapid metabolisers convert more codeine to morphine, which can cause respiratory depression. Poor metabolisers form little morphine and get poor pain relief. This is a classic example of pharmacogenetics.
Answer
A · More morphine is formed, increasing the risk of opioid toxicity
13.Med-surg: cardiovascular & respiratory
Answer: D · A full stomach limits the diaphragm and eating is tiring
Why this is the answer
Many people with severe COPD lose weight because breathing uses a lot of energy and large meals cause bloating and breathlessness. Small, nutrient-dense meals help maintain weight and muscle strength.
Answer
D · A full stomach limits the diaphragm and eating is tiring
14.Med-surg: cardiovascular & respiratory
Answer: A · Magnesium sulfate
Why this is the answer
A single dose of IV magnesium sulfate is recommended in acute severe or life-threatening asthma that does not respond to initial treatment. Senior and critical care help is called early. Sedatives and beta-blockers are dangerous in acute asthma.
Answer
A · Magnesium sulfate
15.Med-surg: neuro, endocrine & renal
Answer: C · Weakness on the same side and loss of pain on the opposite side
Why this is the answer
Damage to one side of the spinal cord, often from a stab wound, causes motor loss and loss of proprioception on the same side, and loss of pain and temperature on the opposite side. The pain fibres cross soon after entering the cord.
Answer
C · Weakness on the same side and loss of pain on the opposite side
16.Med-surg: neuro, endocrine & renal
Answer: C · A honeymoon phase, but insulin is still needed
Why this is the answer
After diagnosis and correction of high glucose, remaining beta cells may work better for a while, so insulin needs fall. This honeymoon phase is temporary. The doses are reduced, but insulin is not stopped.
Answer
C · A honeymoon phase, but insulin is still needed
17.Med-surg: GI, perioperative & oncology
Answer: D · It increases bleeding, wound infection and heart complications
Why this is the answer
Even mild hypothermia impairs clotting, increases surgical site infection and cardiac events, and causes shivering and discomfort. Forced-air warming, warmed fluids and covering the patient help prevent it.
Answer
D · It increases bleeding, wound infection and heart complications
18.Med-surg: GI, perioperative & oncology
Answer: A · Never intrathecal; supplied in a minibag for IV use only
Why this is the answer
Intrathecal vincristine is almost always fatal. To prevent wrong-route errors, it is diluted in a minibag for IV use, labelled "for intravenous use only, fatal if given by other routes" and kept separate from intrathecal drugs.
Answer
A · Never intrathecal; supplied in a minibag for IV use only
19.Maternity & obstetric nursing
Answer: C · Warfarin crosses the placenta and can harm the fetus
Why this is the answer
Warfarin crosses the placenta and is teratogenic and can cause fetal bleeding. Heparins are large molecules that do not cross the placenta, so low molecular weight heparin is commonly used instead.
Answer
C · Warfarin crosses the placenta and can harm the fetus
20.Maternity & obstetric nursing
Answer: B · It may be a sign of an underlying spinal defect
Why this is the answer
A sacral dimple with a hair tuft, swelling or skin change may indicate spina bifida occulta or a tethered cord. It should be reported, and spinal ultrasound is often arranged.
Answer
B · It may be a sign of an underlying spinal defect
21.Pediatric nursing
Answer: C · 1250 mL per day
Why this is the answer
First 10 kg: 10 × 100 = 1000 mL. Next 5 kg: 5 × 50 = 250 mL. Total = 1250 mL per day, or about 52 mL per hour.
Answer
C · 1250 mL per day
22.Pediatric nursing
Answer: C · Usually not; the child was most infectious before the rash appeared
Why this is the answer
In fifth disease the child is most infectious during the mild illness before the rash. By the time the rash appears, the child is usually no longer infectious and does not need to be kept off school.
Answer
C · Usually not; the child was most infectious before the rash appeared
23.Mental health nursing
Answer: D · About 6–24 hours after the last drink
Why this is the answer
Minor withdrawal symptoms begin within hours, usually 6–24 hours after the last drink. Seizures are most likely in the first 1–2 days, and delirium tremens usually appears later, around 2–3 days.
Answer
D · About 6–24 hours after the last drink
24.Mental health nursing
Answer: A · "What are your thoughts about the options you have?"
Why this is the answer
Asking the patient to explore her own options supports problem-solving and autonomy. Giving an opinion, or passing the question on, takes the decision away from her.
Answer
A · "What are your thoughts about the options you have?"
25.Nursing math & unit conversions
Answer: T = 35.6 °C
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.
Subtract 32
96.1 − 32 = 64.1
Multiply by 5/9
T = 64.1·5/9 = 35.61 ≈ 35.6 °C
Answer
T = 35.6 °C
26.Nursing math & unit conversions
Answer: t = 690 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
21:30 → 24:00 = 150 min
After midnight
00:00 → 09:00 = 540 min
Total
t = 150 + 540 = 690 min
Answer
t = 690 min
27.Dosage calculations
Answer: V = 4 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 = 2.5·16 = 40 mg
Volume
V = 40/10 = 4 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4 mL
28.Dosage calculations
Answer: V = 0.88 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 = 4400/5000 = 0.88 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.88 mL
29.IV infusion rates
Answer: V = 450 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
50·60/20 = 150 mL/h
Volume
V = 150·3 = 450 mL
Answer
V = 450 mL
30.IV infusion rates
Answer: D = 20 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
50000 mcg/500 mL = 100 mcg/mL
Dose per hour
12·100 = 1200 mcg/h
Dose per minute
D = 1200/60 = 20 mcg/min
Answer
D = 20 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 40.5 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.
Units per hour
15·108 = 1 620 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1620/40 = 40.5 mL/h
Answer
R = 40.5 mL/h
32.Pediatric & critical-care dosing
Answer: R = 5.2 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
500 mg = 500 000 mcg
500 000/250 = 2000 mcg/mL
Dose per minute and per hour
2.5·69 = 172.5 mcg/min
172.5·60 = 10350 mcg/h
Pump rate
R = 10350/2000 = 5.175 ≈ 5.2 mL/h
Answer
R = 5.2 mL/h
33.IV fluids & fluid balance
Answer: B = −110 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: 100 + 100 = 200 mL
IV infusion: 80·8 = 640 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1040 mL
Total output
200 + 425 + 175 + 250 + 100 = 1150 mL
Balance
B = 1040 − 1150 = −110 mL
Answer
B = −110 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: t = 3.3 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
500 − 250 = 250 mL
Time
t = 250/75 = 3.333 ≈ 3.3 h
Answer
t = 3.3 h
That is about 3 h 20 min, so the bag runs out at about 13:50.
35.Clinical assessment scores
Answer: B = 16
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: no impairment → 4
moisture: very moist → 2
activity: walks frequently → 4
mobility: completely immobile → 1
nutrition: probably inadequate → 2
friction and shear: no apparent problem → 3
Add
Braden total = 4 + 2 + 4 + 1 + 2 + 3 = 16
Answer
B = 16
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 = 47/1.62² = 17.91
Category
underweight
Answer
underweight
37.Arterial blood gas interpretation
Answer: Osm = 303 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 = 2·138 + 18.2 + 9.1 = 303.3 ≈ 303 mOsm/kg
Answer
Osm = 303 mOsm/kg
38.Arterial blood gas interpretation
Answer: pure high-gap acidosis
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 = 139 − (98 + 17) = 24
Delta ratio
(24 − 12)/(24 − 17) = 1.714
pure high-gap acidosis
Answer
pure high-gap acidosis
39.ECG rhythm strip interpretation
Answer: QTc = 0.415 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 9.5 × 0.04 = 0.38 s
RR = 21 × 0.04 = 0.84 s
Bazett’s formula
QTc = 0.38/√0.84 = 0.38/0.9165 = 0.415 s
Answer
QTc = 0.415 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (415 ms)
40.ECG rhythm strip interpretation
Answer: CPR (non-shockable rhythm)
Pulseless electrical activity (PEA): PEA cannot be seen on a strip. The monitor shows organised electrical activity (a rhythm other than VF, VT or asystole) but the patient has no palpable pulse, so it is recognised by checking the patient. In adult resuscitation guidelines PEA and asystole are the non-shockable cardiac arrest rhythms: high-quality CPR, epinephrine as soon as possible and a search for reversible causes (the Hs and Ts, such as hypovolaemia, hypoxia, tension pneumothorax and cardiac tamponade). VF and pulseless VT are the shockable rhythms.
What the strip shows
1. Rate: R–R = 32 small boxes, 1500 ÷ 32 ≈ 47 per minute.
2. Rhythm: regular, every R–R is 1.28 s.
3. P waves: none visible.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s).
junctional rhythm
What the patient shows
no pulse despite organised electrical activity: pulseless electrical activity (PEA), a non-shockable cardiac arrest rhythm
Answer
CPR (non-shockable rhythm)
Answer
CPR (non-shockable rhythm)
PEA is recognised at the bedside, never from the strip alone. This is exam practice, not clinical guidance.