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
A nurse gives a patient analgesia for pain. What is the next important step?
ARecord the dose and assume the pain is gone unless the patient complains
BGive a second dose straight away
CReassess the pain after the drug has had time to work
DWait until the next day to ask about the pain
2.Nursing fundamentalsHard
Five days after hip surgery, a patient suddenly becomes breathless with sharp chest pain and a fast heart rate. What should the nurse suspect?
AAnxiety about going home
BNormal recovery after hip surgery
CA chest infection developing slowly
DA pulmonary embolism
3.Infection control & patient safetyMedium
Which measure reduces errors caused by interruptions during medication preparation?
APreparing medications at the busiest place on the ward
BPreparing medications for all patients at once
CA quiet “no interruption” zone or signal while preparing medications
DAnswering phone calls and pages while counting tablets, to save time
4.Infection control & patient safetyHard
A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?
AAlert staff and security at once, following the missing-patient procedure
BDocument the absence at the end of the shift
CCall the family to ask whether the patient has gone home on their own
DWait an hour in case the patient comes back
5.Prioritization & delegationMedium
A patient has a tonic-clonic seizure in bed. What should the nurse do first?
APlace a tongue depressor between the teeth
BGive a drink of water to help the patient wake
CProtect the head and turn the patient on their side when possible
DHold the arms and legs down firmly to stop the jerking movements quickly
6.Prioritization & delegationHard
A nursing assistant measured vital signs 15 minutes after a patient’s first dose of morphine. They report a respiratory rate of 10/min and say the patient is hard to wake. What should the nurse do?
ADocument the findings and tell the provider at the next scheduled round
BPhone the provider for orders before going to see the patient
CAsk the assistant to recheck the respiratory rate in 15 minutes and report back
DGo at once, rouse the patient, support breathing and prepare naloxone per order
7.Clinical nursingMedium
Which factor is most likely to slow wound healing?
AAdequate fluid intake
BGood blood glucose control
CA diet rich in protein
DSmoking
8.Clinical nursingHard
A postoperative patient on IV fluids has a sodium of 128 mmol/L and is becoming confused. Which fluid could make this worse if given in large amounts?
AHuman albumin solution
BHartmann's solution (similar to lactated Ringer's)
C0.9% sodium chloride
D5% glucose (D5W)
9.Lab values & electrolytesMedium
A patient has a sodium of 152 mEq/L. Which findings would the nurse expect?
AThirst, dry mucous membranes and restlessness
BBradycardia with peaked T waves
CMuscle twitching with a positive Trousseau’s sign
DWeight gain with swollen ankles
10.Lab values & electrolytesHard
A patient with metastatic breast cancer has a calcium of 13.2 mg/dL (3.3 mmol/L), is confused and constipated. Which prescribed treatment would the nurse expect to start first?
AIV 0.9% sodium chloride
BStrict bed rest
COral calcium supplements
DA thiazide diuretic
11.PharmacologyMedium
A patient with a peanut allergy is taught to use an adrenaline auto-injector. Which statement is correct?
AUse it only if the antihistamine has not worked after an hour
BCall emergency services after using it, even if symptoms improve
CKeep it at home so it is not lost
DThere is no need to see a doctor if the swelling goes down
12.PharmacologyHard
A patient receives high-dose IV aciclovir for herpes encephalitis. Which nursing action reduces the main risk to the kidneys?
ARestrict oral and IV fluids to prevent brain swelling
BKeep the patient well hydrated and give the infusion slowly
CGive the infusion as a rapid push
DGive a loop diuretic before each dose
13.Med-surg: cardiovascular & respiratoryMedium
A patient on ramipril is to start sacubitril/valsartan for heart failure. What is the key safety point?
ABoth drugs should be taken together each day for the best effect
BThe ACE inhibitor dose should be doubled during the change
CSacubitril/valsartan is safe to start on the same morning
DThe ACE inhibitor must be stopped first, with a gap before starting
14.Med-surg: cardiovascular & respiratoryHard
Which task for a stable patient with heart failure can the registered nurse most appropriately delegate to a healthcare assistant (unlicensed assistive personnel)?
ATeaching the patient about a low-salt diet
BAssessing lung sounds for new crackles
CMeasuring and recording the morning weight
DDeciding whether to give the furosemide dose
15.Med-surg: neuro, endocrine & renalMedium
What is the main purpose of continuous bladder irrigation after a transurethral resection of the prostate (TURP)?
ATo measure the size of the bladder
BTo give the patient extra fluids
CTo stop blood clots from blocking the catheter
DTo treat a urinary infection after the operation
16.Med-surg: neuro, endocrine & renalHard
A patient on continuous overnight enteral feeding receives insulin timed to the feed. At 02:00 the tube blocks and the feed stops. What is the main risk, and what should the nurse do?
AHypoglycaemia; check glucose often and follow the plan for glucose cover
BKetoacidosis; stop all insulin until the morning
CHyperglycaemia; give an extra dose of insulin straight away
DNo risk; the insulin will simply be stored until feeding restarts
17.Med-surg: GI, perioperative & oncologyMedium
Which technique is correct when giving a prefilled low molecular weight heparin injection?
ALeave the air bubble in and inject into a skin fold
BRub the site firmly afterwards to help absorption
CInject into a vein in the back of the hand
DExpel the air bubble first and inject into the deltoid muscle
18.Med-surg: GI, perioperative & oncologyHard
A patient with diabetes has a foot ulcer. A sterile probe touches bone at the base of the ulcer. What should the nurse suspect?
AOsteomyelitis
BSimple dry skin
CVenous insufficiency
DA healing category 1 ulcer
19.Maternity & obstetric nursingMedium
A woman is 5 days after birth. She cries often, sleeps poorly when the baby sleeps and feels she is a bad mother. What should the nurse do?
AScreen further for depression and self-harm
BAdvise her to stop breastfeeding to rest
CTell her this is the baby blues and will pass
DTell her partner to take over all baby care
20.Maternity & obstetric nursingHard
A newborn is apnoeic after being warmed, dried and stimulated. What is the next step?
AHold the baby upside down and slap the back
BWait and assess the 5-minute APGAR score before doing anything
CStart positive-pressure ventilation with a bag and mask
DStart chest compressions immediately
21.Pediatric nursingMedium
A baby with developmental dysplasia of the hip has a Pavlik harness. Which teaching is correct?
AApply powder and lotion under the straps to protect the skin
BTighten the straps each week as the baby grows
CKeep it on as instructed, do not adjust the straps and check the skin daily
DTake it off every night so the baby can sleep more comfortably and move freely
22.Pediatric nursingHard
A healthy breastfed baby has lost 7% of her birth weight on day 3. What is the best interpretation?
AThis is within the usual range; observe a feed and follow the weight
BThis shows breastfeeding has failed, so formula should replace breast milk from now on
CThis is severe dehydration and needs immediate IV fluids
DThis weight loss is only normal in formula-fed babies
23.Mental health nursingMedium
Which preparation is usual before electroconvulsive therapy (ECT)?
AEating a large meal to prevent low blood sugar during the seizure
BNo preparation, because the patient stays fully awake during ECT
CFasting for several hours, because a brief general anaesthetic is given
DStopping all regular medicines for 2 weeks before the first treatment
24.Mental health nursingHard
A man with gambling disorder has lost his savings and has large debts. He tells the nurse, "My family would be better off without me." What should the nurse do?
AFocus only on helping him create a budget
BAsk directly about suicidal thoughts and plans, and assess his risk
CReassure him that his family will forgive him
DChange the subject to his gambling triggers and how to avoid the betting shop
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 8 lb 1 oz. Using 1 lb = 16 oz and 1 kg = 2.2 lb, find the weight m in kilograms. Round to two decimal places.
8 lb 1 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 17:50 and finishes at 03:00 the next morning (24-hour clock). How many hours t did it run? Give the answer in hours as a decimal, rounded to two decimal places.
17:5003:00
t = h
27.Dosage calculationsMedium
A child weighing 18 kg is prescribed 7.5 mg/kg of a drug. The stock solution contains 25 mg/mL. Draw up the dose: what volume V do you give?
18 kg7.5 mg/kg25 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 375 micrograms. The ampoule contains 0.5 mg/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
375 mcg0.5 mg/mL
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 150 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
150 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 30 gtt/min through a set of 20 gtt/mL. There are 400 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
30 gtt/min20 gtt/mL400 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 70 units/kg for a patient who weighs 64 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
70 units/kg64 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 250 mg in 250 mL runs at 30 mL/h. The patient weighs 76 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL30 mL/h76 kg
D = mcg/kg/min
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 50 mL/h. At 17:30, 550 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL550 mL infused50 mL/h
t = h
35.Clinical assessment scoresMedium
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: yes; ambulatory aid: holds on to furniture; IV therapy or saline lock: yes; gait: weak; mental status: overestimates or forgets limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 130 kg and is 195 cm tall. Calculate the BMI and click the WHO weight category.
130 kg195 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 145 mmol/L, glucose 11.8 mmol/L and urea 19.9 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 145 mmol/Lglucose 11.8 mmol/Lurea 19.9 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 30% oxygen shows PaO₂ 66 mmHg (8.8 kPa) and PaCO₂ 53 mmHg (7.1 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
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
1sinus arrhythmia
2sinus bradycardia
3atrial fibrillation
4normal sinus rhythm
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the 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
1junctional rhythm
2idioventricular rhythm
3dual-chamber (AV) paced rhythm
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: C · Reassess the pain after the drug has had time to work
Why this is the answer
Pain should be reassessed after an interval that matches the drug and route. This shows whether the treatment works and whether side effects such as sedation have appeared.
Answer
C · Reassess the pain after the drug has had time to work
2.Nursing fundamentals
Answer: D · A pulmonary embolism
Why this is the answer
Sudden breathlessness, pleuritic chest pain and tachycardia after surgery suggest a clot from the leg has reached the lungs. This is an emergency needing urgent medical review.
Answer
D · A pulmonary embolism
3.Infection control & patient safety
Answer: C · A quiet “no interruption” zone or signal while preparing medications
Why this is the answer
Interruptions during medication preparation are linked to more errors. Many units use quiet zones, vests or signs to show that the nurse should not be interrupted.
Answer
C · A quiet “no interruption” zone or signal while preparing medications
4.Infection control & patient safety
Answer: A · Alert staff and security at once, following the missing-patient procedure
Why this is the answer
A missing vulnerable patient is an emergency. The nurse immediately activates the facility’s missing-patient procedure so a search starts, and the provider and family are informed per policy.
Answer
A · Alert staff and security at once, following the missing-patient procedure
5.Prioritization & delegation
Answer: C · Protect the head and turn the patient on their side when possible
Why this is the answer
During a seizure the nurse protects the patient from injury and turns them to the side to keep the airway clear. Nothing is put in the mouth, movements are not restrained and nothing is given by mouth.
Answer
C · Protect the head and turn the patient on their side when possible
6.Prioritization & delegation
Answer: D · Go at once, rouse the patient, support breathing and prepare naloxone per order
Why this is the answer
Slow breathing and difficulty rousing suggest opioid-induced respiratory depression. The nurse assesses the patient straight away, stimulates them, supports breathing, gives naloxone per order and escalates. Waiting or calling without seeing the patient wastes critical minutes.
Answer
D · Go at once, rouse the patient, support breathing and prepare naloxone per order
7.Clinical nursing
Answer: D · Smoking
Why this is the answer
Smoking causes vasoconstriction and reduces tissue oxygen, slowing healing and increasing infection risk. Poor nutrition, diabetes, infection and steroids also impair healing.
Answer
D · Smoking
8.Clinical nursing
Answer: D · 5% glucose (D5W)
Why this is the answer
The glucose in 5% glucose is metabolised, leaving free water that dilutes the plasma sodium further. Postoperative patients often have raised ADH, so large volumes of hypotonic fluid can cause dangerous hyponatraemia.
Answer
D · 5% glucose (D5W)
9.Lab values & electrolytes
Answer: A · Thirst, dry mucous membranes and restlessness
Why this is the answer
Hypernatremia usually means a water deficit, causing thirst, dry mouth, restlessness, agitation and, if severe, seizures. It is corrected slowly to avoid cerebral edema.
Answer
A · Thirst, dry mucous membranes and restlessness
10.Lab values & electrolytes
Answer: A · IV 0.9% sodium chloride
Why this is the answer
Hypercalcemia causes large urine volumes and dehydration. IV saline restores volume and helps the kidneys excrete calcium; bisphosphonates usually follow. Thiazides reduce calcium excretion, and immobility releases calcium from bone.Checked against:Hypercalcemia · MedlinePlus (NIH) (2026)
Answer
A · IV 0.9% sodium chloride
11.Pharmacology
Answer: B · Call emergency services after using it, even if symptoms improve
Why this is the answer
Anaphylaxis can recur after the adrenaline wears off (a biphasic reaction). The person always calls for help after using it, carries two auto-injectors and uses adrenaline early.
Answer
B · Call emergency services after using it, even if symptoms improve
12.Pharmacology
Answer: B · Keep the patient well hydrated and give the infusion slowly
Why this is the answer
Aciclovir can crystallise in the tubules and cause acute kidney injury. Good hydration, slow infusion and monitoring of kidney function reduce this risk.
Answer
B · Keep the patient well hydrated and give the infusion slowly
13.Med-surg: cardiovascular & respiratory
Answer: D · The ACE inhibitor must be stopped first, with a gap before starting
Why this is the answer
Combining an ACE inhibitor with sacubitril/valsartan greatly increases the risk of angioedema. The ACE inhibitor is stopped and a washout period (usually 36 hours) is observed before starting. Blood pressure, potassium and renal function are monitored.
Answer
D · The ACE inhibitor must be stopped first, with a gap before starting
14.Med-surg: cardiovascular & respiratory
Answer: C · Measuring and recording the morning weight
Why this is the answer
Weighing a stable patient is a routine, measurable task that can be delegated, with the result reported to the nurse. Assessment, patient teaching and clinical decisions about medicines require the registered nurse's judgement and cannot be delegated.
Answer
C · Measuring and recording the morning weight
15.Med-surg: neuro, endocrine & renal
Answer: C · To stop blood clots from blocking the catheter
Why this is the answer
After TURP, the raw prostate bed bleeds, and clots can block the catheter and cause retention and bladder spasms. Continuous irrigation through a three-way catheter keeps the drainage flowing.
Answer
C · To stop blood clots from blocking the catheter
16.Med-surg: neuro, endocrine & renal
Answer: A · Hypoglycaemia; check glucose often and follow the plan for glucose cover
Why this is the answer
If a feed stops while insulin given to cover it is still acting, the patient can become hypoglycaemic. The nurse checks glucose frequently, informs the team, restores feeding if possible and follows the prescribed plan (for example IV glucose) until feeding restarts. Basal insulin is not simply stopped in type 1 diabetes.
Answer
A · Hypoglycaemia; check glucose often and follow the plan for glucose cover
17.Med-surg: GI, perioperative & oncology
Answer: A · Leave the air bubble in and inject into a skin fold
Why this is the answer
LMWH is injected into a pinched skin fold, often on the abdomen, away from the umbilicus. The air bubble in prefilled syringes is left in, and the site is not rubbed, to reduce bruising.
Answer
A · Leave the air bubble in and inject into a skin fold
18.Med-surg: GI, perioperative & oncology
Answer: A · Osteomyelitis
Why this is the answer
A positive probe-to-bone test in a diabetic foot ulcer strongly suggests osteomyelitis. Imaging, bone samples, prolonged antibiotics and specialist foot team care are usually needed.
Answer
A · Osteomyelitis
19.Maternity & obstetric nursing
Answer: A · Screen further for depression and self-harm
Why this is the answer
Insomnia even when the baby sleeps and feelings of worthlessness can point to depression. The nurse should screen further, including asking directly about self-harm, and arrange follow-up.
Answer
A · Screen further for depression and self-harm
20.Maternity & obstetric nursing
Answer: C · Start positive-pressure ventilation with a bag and mask
Why this is the answer
If the newborn is apnoeic or gasping, or the heart rate is below 100/min after the initial steps, positive-pressure ventilation starts within the first minute. Effective ventilation is the most important step in newborn resuscitation.
Answer
C · Start positive-pressure ventilation with a bag and mask
21.Pediatric nursing
Answer: C · Keep it on as instructed, do not adjust the straps and check the skin daily
Why this is the answer
The Pavlik harness holds the hips flexed and abducted so the joint can develop normally. It is usually worn full-time as directed; only the clinic adjusts the straps. Skin is checked daily, and lotions and powders are avoided.
Answer
C · Keep it on as instructed, do not adjust the straps and check the skin daily
22.Pediatric nursing
Answer: A · This is within the usual range; observe a feed and follow the weight
Why this is the answer
Newborns commonly lose up to about 7–10% of birth weight in the first days and usually regain it by about 2 weeks. At this level, observing a feed, checking latch and nappy output and rechecking weight are appropriate.
Answer
A · This is within the usual range; observe a feed and follow the weight
23.Mental health nursing
Answer: C · Fasting for several hours, because a brief general anaesthetic is given
Why this is the answer
ECT is given under brief general anaesthesia with a muscle relaxant, so pre-procedure fasting is needed. Vital signs, consent and removal of dentures, jewellery and nail varnish are checked as per policy.
Answer
C · Fasting for several hours, because a brief general anaesthetic is given
24.Mental health nursing
Answer: B · Ask directly about suicidal thoughts and plans, and assess his risk
Why this is the answer
Gambling disorder is associated with a raised risk of suicide, especially with debt, shame and hopelessness. The statement is a warning sign that needs direct questions and risk assessment.
Answer
B · Ask directly about suicidal thoughts and plans, and assess his risk
25.Nursing math & unit conversions
Answer: m = 3.66 kg
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Ounces to pounds
1 oz/16 = 0.0625 lb
8 + 0.0625 = 8.063 lb
Pounds to kilograms
m = 8.063/2.2 = 3.665 ≈ 3.66 kg
Answer
m = 3.66 kg
26.Nursing math & unit conversions
Answer: t = 9.17 h
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
17:50 → 24:00 = 370 min
After midnight
00:00 → 03:00 = 180 min
Total
370 + 180 = 550 min
t = 550/60 = 9.167 ≈ 9.17 h
Answer
t = 9.17 h
27.Dosage calculations
Answer: V = 5.4 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 = 7.5·18 = 135 mg
Volume
V = 135/25 = 5.4 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 5.4 mL
28.Dosage calculations
Answer: V = 0.75 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.
Same units
0.5 mg/mL = 500 mcg/mL
Volume
V = 375/500 = 0.75 mL
Answer
V = 0.75 mL
29.IV infusion rates
Answer: R = 150 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.
Millilitres per minute
150/60 = 2.5 mL/min
Drip rate
R = 2.5·60 = 150 gtt/min
Answer
R = 150 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: t = 4.4 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
30·60/20 = 90 mL/h
Time left
t = 400/90 = 4.444 ≈ 4.4 h
Answer
t = 4.4 h
31.Pediatric & critical-care dosing
Answer: V = 4.5 mL
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 needed
70·64 = 4 480 units
Volume
V = 4480/1000 = 4.48 ≈ 4.5 mL
Answer
V = 4.5 mL
32.Pediatric & critical-care dosing
Answer: D = 6.6 mcg/kg/min
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
250 000/250 = 1000 mcg/mL
Micrograms per minute
30·1000 = 30000 mcg/h
30000/60 = 500 mcg/min
Per kilogram
D = 500/76 = 6.579 ≈ 6.6 mcg/kg/min
Answer
D = 6.6 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = 1035 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: 150 + 150 = 300 mL
ice chips: 200/2 = 100 mL
IV infusion: 80·12 = 960 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1560 mL
Total output
225 + 300 = 525 mL
Balance
B = 1560 − 525 = 1035 mL
Answer
B = 1035 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 9 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
1000 − 550 = 450 mL
Time
t = 450/50 = 9 h
Answer
t = 9 h
That is about 9 h 00 min, so the bag runs out at about 02:30.
35.Clinical assessment scores
Answer: MFS = 90
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: yes → 15
ambulatory aid: holds on to furniture → 30
IV therapy or saline lock: yes → 20
gait: weak → 10
mental status: overestimates or forgets limits → 15
Add
Morse total = 0 + 15 + 30 + 20 + 10 + 15 = 90
Answer
MFS = 90
36.Clinical assessment scores
Answer: obesity class I
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 = 130/1.95² = 34.19
Category
obesity class I
Answer
obesity class I
37.Arterial blood gas interpretation
Answer: Osm = 322 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 = 2·145 + 11.8 + 19.9 = 321.7 ≈ 322 mOsm/kg
Answer
Osm = 322 mOsm/kg
38.Arterial blood gas interpretation
Answer: A–a gradient = 81.65 mmHg
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.
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 1.02 s, lengthening and shortening gradually.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.16 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: dual-chamber (AV) paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 25 small boxes, 1500 ÷ 25 ≈ 60 per minute.
2. Rhythm: regular, every R–R is 1.00 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.18 s after the first one (the programmed AV delay).
5. QRS: 0.16 s, wide, right after the second spike (ventricular pacing).
Interpretation
dual-chamber (AV) paced rhythm
Answer
dual-chamber (AV) paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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