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
Why is an IV giving set primed before connecting it to the patient?
ATo warm the fluid to body temperature
BTo remove air from the line
CTo check the speed of the pump
DTo test whether the patient is allergic to the fluid
2.Nursing fundamentalsHard
A healthcare assistant (nursing assistant) has recorded a blood pressure of 82/50 mmHg during routine observations but did not report it. What should the registered nurse do first?
AComplete an incident report
BAssess the patient straight away
CTalk to the healthcare assistant about reporting
DRepeat the observations at the next routine time
3.Infection control & patient safetyMedium
A nurse has been fit-tested for an N95 respirator. What should the nurse do each time it is put on?
APerform a user seal check
BMoisten the edges so it seals better
CArrange a new fit test
DWear a surgical mask underneath it
4.Infection control & patient safetyHard
A nurse calculates a child’s prescribed dose and finds it is ten times higher than the usual dose for the child’s weight. What should the nurse do?
AGive half the dose and watch the child closely
BGive it, because the prescriber must have a reason
CGive one-tenth of the dose without telling anyone about it
DHold the dose and verify it with the prescriber and pharmacist
5.Prioritization & delegationMedium
A drowsy patient has an arterial blood gas with pH 7.30, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?
AHyperventilation caused by anxiety
BPoor ventilation causing carbon dioxide to build up
CLoss of bicarbonate from the bowel through severe diarrhea
DToo much bicarbonate from antacids
6.Prioritization & delegationHard
After report, which patient should the nurse assess first?
ADay 2 after gallbladder surgery: pain 6/10, next analgesic due in 30 minutes
BType 2 diabetes: glucose 210 mg/dL (11.7 mmol/L) before lunch, no symptoms
CCOPD on 2 L/min oxygen: SpO₂ 90%, respiratory rate 22/min, at usual baseline
D1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
7.Clinical nursingMedium
Which advice is important for a patient on long-term oral corticosteroids?
ADouble the dose if a dose is missed
BDo not stop them suddenly
CTake them on an empty stomach at night
DTake them only when symptoms flare
8.Clinical nursingHard
A patient who has had a kidney stone is taught about prevention. Which statement shows a need for further teaching?
A"I will follow the diet advice for my stone type."
B"I will aim to drink plenty of fluids spread through every day."
C"I will drink less water so I don't need to pass urine as often."
D"I will try to pass pale urine."
9.Lab values & electrolytesMedium
Why is a blood β-hydroxybutyrate level often preferred to a urine ketone dipstick in DKA?
AIt is the only test that can measure glucose and ketones together
BThe urine dipstick only detects ketones in people without diabetes
CIt measures the main ketone in DKA, and the dipstick may miss it
DIt shows the average ketone level over the past three months
10.Lab values & electrolytesHard
A patient's total calcium is 7.6 mg/dL and the albumin is 2.0 g/dL. Using the common correction (add 0.8 mg/dL for each 1 g/dL that albumin is below 4.0), what is the corrected calcium?
A9.2 mg/dL, within the normal range
B11.6 mg/dL, above the normal range
C7.6 mg/dL, below the normal range
D6.0 mg/dL, well below the normal range
11.PharmacologyMedium
A 19-year-old starts an SSRI for depression. Which is most important for the nurse to monitor during the first weeks?
ANew or worsening suicidal thoughts or agitation
BHearing loss and tinnitus
CDaily bowel movements only
DBlood glucose before every meal and at bedtime
12.PharmacologyHard
An older patient with coronary artery disease is starting levothyroxine for hypothyroidism. Why is a low starting dose used?
ALevothyroxine causes severe hypoglycaemia in older patients
BHigh starting doses cause permanent hypothyroidism
COlder patients absorb levothyroxine much better, so small doses are all they need
DFast replacement raises cardiac oxygen demand and can cause angina
13.Med-surg: cardiovascular & respiratoryMedium
Shortly after a permanent pacemaker is inserted via the subclavian vein, the patient becomes breathless with reduced breath sounds on that side. What complication should be suspected?
AAsthma
BPulmonary oedema
CPericarditis
DPneumothorax
14.Med-surg: cardiovascular & respiratoryHard
A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?
AA low-dose opioid with a hand-held fan and calm positioning
BStopping all medicines, including inhalers
CEncouraging long walks to build fitness
DHigh-flow oxygen at 15 L/min whatever the oxygen saturation is
15.Med-surg: neuro, endocrine & renalMedium
Before a haemodialysis catheter is used, why is the lock solution withdrawn from each lumen?
AIt contains a strong antibiotic that must be kept
BIt contains air that keeps the line open
CIt contains concentrated anticoagulant
DIt contains the patient's urine
16.Med-surg: neuro, endocrine & renalHard
An 89-year-old with stage 5 CKD and severe heart failure, who has capacity, decides not to start dialysis. What is the nurse's best response?
AAsk the family to change the patient's mind
BTell the patient they must start dialysis by law
CStop all care, because nothing more can be done
DRespect the decision and support symptom-focused care
17.Med-surg: GI, perioperative & oncologyMedium
A patient with cirrhosis takes lactulose for hepatic encephalopathy. What is the usual aim?
ANo bowel movement for several days
BOne firm stool every week
CTwo to three soft stools a day
DTen or more watery stools a day
18.Med-surg: GI, perioperative & oncologyHard
Which history should most alert the nurse to a possible latex allergy before surgery?
AA rash after taking amoxicillin as a child, with a family history of asthma
BFeeling sick after eating shellfish once
CHay fever every spring since childhood
DItching with bananas, avocado and kiwi, and many operations
19.Maternity & obstetric nursingMedium
A woman with hyperemesis gravidarum has been vomiting for weeks. Which vitamin is given before glucose-containing fluids to prevent Wernicke encephalopathy?
APhytomenadione (vitamin K)
BVitamin D
CThiamine (vitamin B1)
DAscorbic acid (vitamin C)
20.Maternity & obstetric nursingHard
A newborn is jaundiced at 12 hours of age. The mother is blood group O, Rh-positive and the baby is group A, Rh-positive with a positive direct Coombs test. What is the most likely cause?
ABreast milk jaundice
BRh isoimmunisation
CABO incompatibility
DPhysiological jaundice
21.Pediatric nursingMedium
When is the risk of bleeding after a tonsillectomy highest?
AThe risk stays exactly the same on every day for the first month
BIn the first 24 hours and again about 5 to 10 days later
COnly during the first 2 hours after surgery
DOnly after 3 weeks, when the throat is fully healed
22.Pediatric nursingHard
A baby born at 28 weeks is now 6 months old. He is not yet sitting without support. How should the nurse interpret this?
AMilestones are judged by corrected age, here about 3 months, so this is expected
BMilestones are always judged by chronological age, so he is 3 months behind
CPreterm babies never reach normal milestones, so no follow-up is needed
DHe is clearly delayed and needs urgent neurological referral
23.Mental health nursingMedium
Which criteria are needed for a diagnosis of intellectual disability?
AAn IQ score alone, measured at any time in adult life
BLimits in both intellectual and adaptive functioning, starting in childhood
CProblems with reading only, with normal everyday functioning
DMemory loss and confusion that start for the first time after the age of 65
24.Mental health nursingHard
A patient starting clozapine is being taught about blood tests. Which statement shows a need for further teaching?
A"After a few months I can stop having blood tests."
B"If I get a sore throat or fever, I'll tell someone straight away."
C"The tests are done because clozapine can lower my white cells."
D"I'll need regular blood tests for as long as I take clozapine."
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 105.2 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
105.2 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A maintenance infusion runs at 60 mL/h without a break. How many litres V does it deliver in 24 hours?
60 mL/h24 h
V = L
27.Dosage calculationsMedium
A patient weighs 45 kg. The prescribed dose is 30 mg/kg per day, given in 4 equal doses. How many milligrams D are given per dose?
45 kg30 mg/kg/day4× per day
D = mg
28.Dosage calculationsHard
An infusion contains 50000 units of a drug in 250 mL. The prescription is 1500 units per hour. At what rate R do you set the pump, in mL/h?
50000 units/250 mL1500 units/h
R = mL/h
29.IV infusion ratesMedium
Infuse 1000 mL over 10 hours with a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
1000 mL10 h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 42 gtt/min through a set of 15 gtt/mL. There are 300 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
42 gtt/min15 gtt/mL300 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 16 units/kg/h for a patient who weighs 51 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL16 units/kg/h51 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 2.5 mcg/kg/min for a patient who weighs 109 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL2.5 mcg/kg/min109 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 07:30 at 75 mL/h. After 2 hours the rate is changed to 125 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 mL75 mL/h · 2 h125 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 104/min and a blood pressure of 72/40 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 104/minBP 72/40 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 129 kg and is 154 cm tall. Calculate the BMI and click the WHO weight category.
129 kg154 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 137 mmol/L, glucose 29 mmol/L and urea 11.1 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 137 mmol/Lglucose 29 mmol/Lurea 11.1 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.32, PaCO₂ 32 mmHg (4.3 kPa), HCO₃⁻ 16 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.32PaCO₂ 32 mmHg (4.3 kPa)HCO₃⁻ 16 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
39.ECG rhythm strip interpretationMedium
Interpret this lead II rhythm strip. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1normal sinus rhythm
2atrial fibrillation
3sinus bradycardia
4sinus arrhythmia
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. Measure the P–P interval and find the atrial 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
atrial rate = bpm
3Solutions
1.Nursing fundamentals
Answer: B · To remove air from the line
Why this is the answer
Priming fills the line with fluid and removes air, which could otherwise enter the vein and cause an air embolism.
Answer
B · To remove air from the line
2.Nursing fundamentals
Answer: B · Assess the patient straight away
Why this is the answer
A low blood pressure may mean deterioration, so the nurse assesses the patient at once and escalates if needed. Feedback to the assistant and reporting follow afterwards.
Answer
B · Assess the patient straight away
3.Infection control & patient safety
Answer: A · Perform a user seal check
Why this is the answer
A fit test confirms that a model and size suit the person. A user seal check, breathing in and out to feel for leaks at the edges, is done every time the respirator is put on.
Answer
A · Perform a user seal check
4.Infection control & patient safety
Answer: D · Hold the dose and verify it with the prescriber and pharmacist
Why this is the answer
Tenfold errors are common in pediatrics, usually from decimal or unit mistakes. The nurse holds the dose and clarifies it, and never changes the dose on their own.
Answer
D · Hold the dose and verify it with the prescriber and pharmacist
5.Prioritization & delegation
Answer: B · Poor ventilation causing carbon dioxide to build up
Why this is the answer
A low pH with a high PaCO₂ and normal bicarbonate is respiratory acidosis. The patient is not breathing out enough carbon dioxide, so the priority is to support ventilation and escalate.
Answer
B · Poor ventilation causing carbon dioxide to build up
6.Prioritization & delegation
Answer: D · 1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
Why this is the answer
Back pain, tachycardia and hypotension after a femoral puncture suggest retroperitoneal bleeding, which can be hidden and fatal. The COPD patient is at baseline, the pain is expected and being treated, and the glucose is high but not an emergency.
Answer
D · 1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
7.Clinical nursing
Answer: B · Do not stop them suddenly
Why this is the answer
Long-term steroids suppress the adrenal glands, so stopping suddenly can cause adrenal crisis. Patients should carry a steroid alert card or medical ID and follow sick-day guidance.
Answer
B · Do not stop them suddenly
8.Clinical nursing
Answer: C · "I will drink less water so I don't need to pass urine as often."
Why this is the answer
A high fluid intake dilutes urine and is the most important general measure to prevent stones. Dietary advice depends on the stone's composition.
Answer
C · "I will drink less water so I don't need to pass urine as often."
9.Lab values & electrolytes
Answer: C · It measures the main ketone in DKA, and the dipstick may miss it
Why this is the answer
In DKA, β-hydroxybutyrate is the main ketone, but most urine dipsticks detect acetoacetate, so they can underestimate ketosis. Blood β-hydroxybutyrate gives a current value that is also useful to monitor recovery.
Answer
C · It measures the main ketone in DKA, and the dipstick may miss it
10.Lab values & electrolytes
Answer: A · 9.2 mg/dL, within the normal range
Why this is the answer
Corrected calcium = 7.6 + 0.8 × (4.0 − 2.0) = 9.2 mg/dL, which is normal. Low albumin lowers the bound fraction of calcium; the correction is only an estimate, and an ionized calcium is more accurate when it matters.
Answer
A · 9.2 mg/dL, within the normal range
11.Pharmacology
Answer: A · New or worsening suicidal thoughts or agitation
Why this is the answer
Antidepressants can increase suicidal thinking in young people, especially early in treatment or after dose changes. Close follow-up and a clear plan for reporting such thoughts are essential.
Answer
A · New or worsening suicidal thoughts or agitation
12.Pharmacology
Answer: D · Fast replacement raises cardiac oxygen demand and can cause angina
Why this is the answer
Thyroid hormone increases metabolic rate, heart rate and contractility. In older people and those with heart disease, the dose is started low and increased slowly to avoid ischaemia and arrhythmias.
Answer
D · Fast replacement raises cardiac oxygen demand and can cause angina
13.Med-surg: cardiovascular & respiratory
Answer: D · Pneumothorax
Why this is the answer
Subclavian puncture can injure the pleura and cause a pneumothorax. A chest X-ray is usually taken after implantation. Other complications include haematoma, lead displacement and infection.
Answer
D · Pneumothorax
14.Med-surg: cardiovascular & respiratory
Answer: A · A low-dose opioid with a hand-held fan and calm positioning
Why this is the answer
Low-dose oral opioids can ease refractory breathlessness in advanced disease. A fan blowing air across the face, upright positioning, breathing techniques and anxiety management also help. Oxygen is used only if it relieves symptoms or corrects hypoxaemia.
Answer
A · A low-dose opioid with a hand-held fan and calm positioning
15.Med-surg: neuro, endocrine & renal
Answer: C · It contains concentrated anticoagulant
Why this is the answer
Dialysis catheter lumens are filled with a concentrated heparin or citrate lock. If it is flushed into the patient, it can cause bleeding or other effects. Catheters are usually accessed only by trained staff.
Answer
C · It contains concentrated anticoagulant
16.Med-surg: neuro, endocrine & renal
Answer: D · Respect the decision and support symptom-focused care
Why this is the answer
A competent patient can refuse dialysis. The nurse makes sure the choice is informed, respects it and supports conservative kidney management, with symptom control, advance care planning and palliative care input.
Answer
D · Respect the decision and support symptom-focused care
17.Med-surg: GI, perioperative & oncology
Answer: C · Two to three soft stools a day
Why this is the answer
Lactulose acidifies the colon and traps ammonia, and it speeds transit. The dose is titrated to 2–3 soft stools a day. Excessive diarrhoea can cause dehydration and electrolyte disturbance that worsen encephalopathy.
Answer
C · Two to three soft stools a day
18.Med-surg: GI, perioperative & oncology
Answer: D · Itching with bananas, avocado and kiwi, and many operations
Why this is the answer
Latex–fruit syndrome links latex allergy with foods such as banana, avocado, kiwi and chestnut. Repeated exposure, for example through many operations or catheters, also increases risk.
Answer
D · Itching with bananas, avocado and kiwi, and many operations
19.Maternity & obstetric nursing
Answer: C · Thiamine (vitamin B1)
Why this is the answer
Prolonged vomiting depletes thiamine. Giving glucose without thiamine can trigger Wernicke encephalopathy, with confusion, ataxia and eye movement problems.
Answer
C · Thiamine (vitamin B1)
20.Maternity & obstetric nursing
Answer: C · ABO incompatibility
Why this is the answer
Group O mothers have anti-A and anti-B antibodies that can cross the placenta and haemolyse the red cells of a group A or B baby. Early jaundice with a positive direct Coombs test suggests haemolysis. Both are Rh-positive, so Rh disease is excluded.
Answer
C · ABO incompatibility
21.Pediatric nursing
Answer: B · In the first 24 hours and again about 5 to 10 days later
Why this is the answer
Primary bleeding occurs in the first 24 hours. Secondary bleeding occurs around 5–10 days after surgery, when the scabs come away, so families need to know the warning signs before going home.
Answer
B · In the first 24 hours and again about 5 to 10 days later
22.Pediatric nursing
Answer: A · Milestones are judged by corrected age, here about 3 months, so this is expected
Why this is the answer
Born 12 weeks early, his corrected age is about 3 months, when sitting is not expected. Corrected age is used for development and growth in preterm babies, usually until about 2 years, while vaccines follow chronological age.
Answer
A · Milestones are judged by corrected age, here about 3 months, so this is expected
23.Mental health nursing
Answer: B · Limits in both intellectual and adaptive functioning, starting in childhood
Why this is the answer
Intellectual disability requires limitations in intellectual functions and in adaptive functioning, such as communication, self-care and social skills, starting in childhood. Severity is based mainly on adaptive functioning.
Answer
B · Limits in both intellectual and adaptive functioning, starting in childhood
24.Mental health nursing
Answer: A · "After a few months I can stop having blood tests."
Why this is the answer
Blood count monitoring is most frequent in the first months of clozapine treatment but continues throughout treatment, because agranulocytosis can occur at any time.
Answer
A · "After a few months I can stop having blood tests."
25.Nursing math & unit conversions
Answer: T = 40.7 °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
105.2 − 32 = 73.2
Multiply by 5/9
T = 73.2·5/9 = 40.67 ≈ 40.7 °C
Answer
T = 40.7 °C
26.Nursing math & unit conversions
Answer: V = 1.44 L
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.
Volume in a day
60 mL/h × 24 h = 1440 mL
In litres
V = 1440/1000 = 1.44 L
Answer
V = 1.44 L
27.Dosage calculations
Answer: D = 337.5 mg
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.
Total per day
30·45 = 1350 mg
Per dose
D = 1350/4 = 337.5 mg
Answer
D = 337.5 mg
28.Dosage calculations
Answer: R = 7.5 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
50000/250 = 200 units/mL
Pump rate
R = 1500/200 = 7.5 mL/h
Answer
R = 7.5 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
10·60 = 600 min
Drip rate
R = 1000·60/600 = 100 gtt/min
Answer
R = 100 gtt/min
30.IV infusion rates
Answer: t = 1.8 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
42·60/15 = 168 mL/h
Time left
t = 300/168 = 1.786 ≈ 1.8 h
Answer
t = 1.8 h
31.Pediatric & critical-care dosing
Answer: R = 8.2 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
16·51 = 816 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 816/100 = 8.16 ≈ 8.2 mL/h
Answer
R = 8.2 mL/h
32.Pediatric & critical-care dosing
Answer: R = 16.4 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
2.5·109 = 272.5 mcg/min
272.5·60 = 16350 mcg/h
Pump rate
R = 16350/1000 = 16.35 ≈ 16.4 mL/h
Answer
R = 16.4 mL/h
33.IV fluids & fluid balance
Answer: B = 540 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: 180 + 150 + 150 = 480 mL
ice chips: 100/2 = 50 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 1·100 = 100 mL
total intake = 1630 mL
Total output
350 + 450 + 250 + 40 = 1090 mL
Balance
B = 1630 − 1090 = 540 mL
Answer
B = 540 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 4.8 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
75·2 = 150 mL
500 − 150 = 350 mL left
Second part
350/125 = 2.8 h
Total time
t = 2 + 2.8 = 4.8 h
Answer
t = 4.8 h
That is about 4 h 48 min, so the bag runs out at about 12:18.
35.Clinical assessment scores
Answer: SI = 1.44
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Shock index
SI = 104/72 = 1.444 ≈ 1.44
Answer
SI = 1.44
1 or more: a warning sign of shock in this practice case.
36.Clinical assessment scores
Answer: obesity class III
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 = 129/1.54² = 54.39
Category
obesity class III
Answer
obesity class III
37.Arterial blood gas interpretation
Answer: Osm = 314 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 = 2·137 + 29 + 11.1 = 314.1 ≈ 314 mOsm/kg
Answer
Osm = 314 mOsm/kg
38.Arterial blood gas interpretation
Answer: appropriate compensation
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
1.5·16 + 8 = 32 → 30–34 mmHg
Compare
measured: 32 mmHg → appropriate compensation
Answer
appropriate compensation
39.ECG rhythm strip interpretation
Answer: sinus arrhythmia
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.
Five steps
1. Rate: 7 QRS complexes in 6 s, × 10 = 70 per minute.
2. Rhythm: irregular, R–R from 0.74 to 1.10 s, lengthening and shortening gradually.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.18 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
sinus arrhythmia
Answer
sinus arrhythmia
40.ECG rhythm strip interpretation
Answer: atrial rate = 83 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 = 18 small boxes = 0.72 s → 1500 ÷ 18 = 83.33 ≈ 83 per minute
Ventricular rate
R–R = 43 small boxes = 1.72 s → 1500 ÷ 43 = 34.88 ≈ 35 per minute
Answer
atrial rate = 83 bpm
Answer
atrial rate = 83 bpm
Third-degree block with a wide-complex ventricular escape (usually 20–40 per minute).
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