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
Which medicine commonly causes constipation?
ADocusate
BCodeine
CSenna
DLactulose
2.Nursing fundamentalsHard
A patient's oxygen saturation target is 88–92%. Which condition most likely explains this lower target?
APneumonia in a previously healthy patient with no chronic lung disease
BAsthma attack in a young adult
CCarbon monoxide poisoning
DChronic obstructive pulmonary disease with risk of hypercapnia
3.Infection control & patient safetyMedium
A patient with a respiratory infection has a raised procalcitonin level. What does this most suggest?
ADehydration from poor intake
BA purely viral illness
CA bacterial rather than a viral infection
DAn allergic reaction to a recent medication
4.Infection control & patient safetyHard
A patient on long-term high-dose corticosteroids asks for the nasal spray influenza vaccine. What should the nurse explain?
AThe nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
BEither type is fine, as long as it is given in the morning
CPeople on steroids should never have any influenza vaccine
DThe nasal spray is the best choice for people on steroids, because it is not injected
5.Prioritization & delegationMedium
A patient taking clozapine reports a sore throat and fever. What is the priority action?
AOffer throat lozenges and continue the usual dose
BAdvise the patient to gargle with warm salt water and rest in bed
CHold the dose and report so the white cell count can be checked
DIncrease the dose because the symptoms suggest a relapse
6.Prioritization & delegationHard
A patient has a new spinal cord injury at C4. Which assessment is the priority?
AAbility to feed themselves
BBreathing effort and ability to cough
CSkin over the sacrum and heels
DBowel sounds in all four abdominal quadrants
7.Clinical nursingMedium
What is the first-line drug treatment for anaphylaxis?
AOral antihistamine such as cetirizine
BIntramuscular adrenaline
CInhaled steroid
DIntravenous paracetamol
8.Clinical nursingHard
A patient with an epidural catheter develops new back pain and increasing leg weakness when the block should be wearing off. What should be suspected?
AMuscle strain from lying in the same position in bed for many hours
BAn epidural haematoma or abscess compressing the spinal cord
CMild hypokalaemia
DThe normal expected effect of the local anaesthetic
9.Lab values & electrolytesMedium
A patient starts lisinopril (an ACE inhibitor). Which laboratory values should the nurse expect to be monitored?
ACalcium and phosphate
BALT and bilirubin
CPotassium and creatinine
DTSH and free T4
10.Lab values & electrolytesHard
A patient with a long-standing lung condition has a serum bicarbonate of 32 mEq/L, an arterial PaCO₂ that is always high and a pH of 7.36. Which condition fits best?
AAcute severe diarrhea with large bicarbonate losses
BAcute diabetic ketoacidosis with severe dehydration and vomiting
CCOPD with chronic CO₂ retention and metabolic compensation
DAcute aspirin overdose with rapid breathing
11.PharmacologyMedium
Why are benzodiazepines used with great caution in older people?
AThey raise the risk of confusion, falls and fractures
BThey are not absorbed from the gut after age 65
CThey cause severe high blood pressure in older people
DThey cause permanent hearing loss in older people
12.PharmacologyHard
Why is the TPMT enzyme often tested before azathioprine is started?
ALow TPMT activity causes toxic levels and marrow suppression
BTPMT testing shows whether the patient has tuberculosis
CTPMT is needed to absorb azathioprine from the gut
DHigh TPMT activity causes an allergic reaction to azathioprine
13.Med-surg: cardiovascular & respiratoryMedium
Why is a raised serum lactate concerning in a patient with shock?
AIt confirms a bacterial infection is present
BIt shows only that the patient has eaten a large meal in the past hour
CIt suggests tissues are short of oxygen and using anaerobic metabolism
DIt means the kidneys are working harder than normal to clear fluid
14.Med-surg: cardiovascular & respiratoryHard
During a severe asthma attack, a patient's PaCO₂ rises from low to normal while they look exhausted. What does this mean?
AThe attack is resolving and treatment can be reduced
BThe sample is probably venous and can be ignored
CThe patient is tiring and respiratory failure may follow
DThe patient is hyperventilating because of anxiety
15.Med-surg: neuro, endocrine & renalMedium
A urine dipstick is positive for nitrites. What does this suggest?
AThe kidneys are losing too much protein
BThe patient is dehydrated and needs more fluid
CBacteria that convert nitrate are present
DThe urine has a lot of glucose in it
16.Med-surg: neuro, endocrine & renalHard
A patient on carbamazepine is admitted confused, with a sodium of 121 mmol/L. Which explanation is most likely?
AThe low sodium proves the patient has stopped taking the drug
BCarbamazepine causes salt loss through severe diarrhoea
CCarbamazepine can cause hyponatraemia through an SIADH-like effect
DConfusion is a normal, expected effect of carbamazepine and is unrelated to sodium
17.Med-surg: GI, perioperative & oncologyMedium
Which is a recognised side effect of ondansetron?
AConstipation
BSevere hypoglycaemia
CHearing loss
DHair loss
18.Med-surg: GI, perioperative & oncologyHard
In recovery, an awake and anxious patient cannot lift their head, and their breaths are shallow and weak. What is the most likely cause?
AResidual neuromuscular blockade
BNormal tiredness after surgery
COpioid overdose with pinpoint pupils
DA simple panic attack
19.Maternity & obstetric nursingMedium
Which newborn complication is particularly linked to a forceps birth?
AFacial nerve palsy
BNeonatal jaundice from ABO incompatibility
CUmbilical hernia
DHip dysplasia
20.Maternity & obstetric nursingHard
A woman who had a stillbirth asks the nurse why it happened. What is the most appropriate response?
AChange the subject to avoid upsetting her
BTell her she should not have exercised
CTell her it was probably something she ate
DAcknowledge her grief; tests may find a cause
21.Pediatric nursingMedium
Which child should generally not receive a live vaccine such as MMR?
AA child whose sibling has a cold
BA child with a mild cold
CA child who is currently taking oral antibiotics for an uncomplicated ear infection
DA child with severe immune suppression, for example during chemotherapy
22.Pediatric nursingHard
A newborn becomes deeply cyanotic within hours of birth and does not improve with oxygen. A prostaglandin infusion is started. What is its purpose?
ATo strengthen heart muscle contraction and raise blood pressure
BTo dilate the airways so that oxygen can reach the alveoli
CTo close the ductus arteriosus and send all blood through the lungs
DTo keep the ductus arteriosus open so that the two circulations can mix
23.Mental health nursingMedium
A patient with limited English needs a mental health assessment. Who should interpret?
AThe patient's 12-year-old son
BThe nurse, using an online translation app on her phone for the whole assessment
CA trained professional interpreter
DAnother patient on the ward who speaks the language
24.Mental health nursingHard
A patient taking venlafaxine has started a second serotonergic medicine. She is restless, sweating, has a fast pulse and twitching muscles. What should the nurse do first?
AGive the next dose of venlafaxine as planned
BHold the serotonergic medicines and inform the prescriber urgently
CEncourage her to walk or exercise in the garden to relieve the restlessness and muscle twitching
DGive paracetamol (acetaminophen) and check her again tomorrow
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 14:40 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
14:40
11:40 PM
24:40 PM
32:40 AM
42:40 PM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 3 mg/h. Express this dose rate D in mcg/min. Round to one decimal place.
3 mg/h1 mg = 1000 mcg1 h = 60 min
D = mcg/min
27.Dosage calculationsMedium
A patient weighs 18 kg and is prescribed 7.5 mg/kg as a single dose. Find the dose D in mg.
18 kg7.5 mg/kg
D = mg
28.Dosage calculationsHard
An infusion contains 40000 units of a drug in 250 mL. The prescription is 1250 units per hour. At what rate R do you set the pump, in mL/h?
40000 units/250 mL1250 units/h
R = mL/h
29.IV infusion ratesMedium
1000 mL was ordered over 12 hours. After 7 hours you find that 470 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
1000 mL / 12 hafter 7 h: 470 mL
R = mL/h
30.IV infusion ratesHard
500 mL was ordered over 12 hours. After 8 hours you find that 210 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
500 mL / 12 hafter 8 h: 210 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 500 mL. The order is 14 units/kg/h for a patient who weighs 50 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL14 units/kg/h50 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 800 mg in 500 mL. The order is 10 mcg/kg/min for a patient who weighs 59 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL10 mcg/kg/min59 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 07:30 and runs by pump at 50 mL/h. How many mL V are left in the bag at 10:00?
1000 mL50 mL/h07:30 → 10:00
V = mL
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: yes; secondary diagnosis: yes; ambulatory aid: crutches, cane or walker; 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). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 24/min, SpO₂ 99% on room air, blood pressure 136/82 mmHg, pulse 104/min, alert, temperature 36.3 °C. Which clinical risk group does the patient fall into? Click it.
RR 24SpO₂ 99%airSBP 136HR 104AT 36.3 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.30, PaCO₂ 51 mmHg (6.8 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory acidosis. How far is it compensated? Click your answer.
pH 7.30PaCO₂ 51 mmHg (6.8 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 146, Cl⁻ 107 and HCO₃⁻ 10 mmol/L. Calculate the delta ratio (AG − 12)/(24 − HCO₃⁻), using AG = Na⁺ − (Cl⁻ + HCO₃⁻). Give two decimals.
Na⁺ 146 mmol/LCl⁻ 107 mmol/LHCO₃⁻ 10 mmol/L
delta ratio =
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
1sinus rhythm with sinus arrest
2sinus arrhythmia
3normal sinus rhythm
4sinus rhythm with PVCs
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. 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
1third-degree (complete) AV block
2first-degree AV block
3junctional rhythm
4second-degree AV block type I (Wenckebach)
3Solutions
1.Nursing fundamentals
Answer: B · Codeine
Why this is the answer
Opioids such as codeine and morphine slow gut movement and commonly cause constipation. Senna, lactulose and docusate are laxatives.
Answer
B · Codeine
2.Nursing fundamentals
Answer: D · Chronic obstructive pulmonary disease with risk of hypercapnia
Why this is the answer
In COPD patients at risk of hypercapnic respiratory failure, too much oxygen can raise CO₂ levels, so a target of 88–92% is used.
Answer
D · Chronic obstructive pulmonary disease with risk of hypercapnia
3.Infection control & patient safety
Answer: C · A bacterial rather than a viral infection
Why this is the answer
Procalcitonin rises mainly in bacterial infections and much less in viral ones. It is used with clinical judgement to help decide when antibiotics are needed or can be stopped.
Answer
C · A bacterial rather than a viral infection
4.Infection control & patient safety
Answer: A · The nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
Why this is the answer
The nasal spray influenza vaccine contains live, weakened virus and is avoided in immunosuppressed people. The inactivated injectable vaccine is safe and recommended for them.
Answer
A · The nasal spray is a live vaccine, so the injected inactivated vaccine is used instead
5.Prioritization & delegation
Answer: C · Hold the dose and report so the white cell count can be checked
Why this is the answer
Clozapine can cause agranulocytosis. A sore throat or fever may be the first sign of infection, so the nurse reports it and the neutrophil count is checked before more doses are given.
Answer
C · Hold the dose and report so the white cell count can be checked
6.Prioritization & delegation
Answer: B · Breathing effort and ability to cough
Why this is the answer
Injuries at C3–C5 can affect the phrenic nerve and diaphragm, so breathing may fail. Respiratory function is monitored closely, and the patient may need ventilatory support.
Answer
B · Breathing effort and ability to cough
7.Clinical nursing
Answer: B · Intramuscular adrenaline
Why this is the answer
Adrenaline IM into the thigh (for adults typically 0.5 mg, i.e. 0.5 mL of 1 mg/mL; US guidance 0.3–0.5 mg) is first line, repeated after 5 minutes if needed. Antihistamines and steroids are not first-line treatments.
Answer
B · Intramuscular adrenaline
8.Clinical nursing
Answer: B · An epidural haematoma or abscess compressing the spinal cord
Why this is the answer
Increasing motor block, back pain or new weakness after an epidural can mean a haematoma or abscess compressing the cord. This is a surgical emergency: stop the infusion and get urgent medical review.
Answer
B · An epidural haematoma or abscess compressing the spinal cord
9.Lab values & electrolytes
Answer: C · Potassium and creatinine
Why this is the answer
ACE inhibitors reduce aldosterone, so potassium can rise, and they lower the filtration pressure in the kidney, so creatinine can rise. Both are checked before and soon after starting or increasing the dose.
Answer
C · Potassium and creatinine
10.Lab values & electrolytes
Answer: C · COPD with chronic CO₂ retention and metabolic compensation
Why this is the answer
In chronic CO₂ retention, as in severe COPD, the kidneys retain bicarbonate over days and bring the pH back towards normal, often to the low end of the range. DKA and diarrhea lower bicarbonate, and aspirin overdose causes rapid breathing that lowers the PaCO₂.
Answer
C · COPD with chronic CO₂ retention and metabolic compensation
11.Pharmacology
Answer: A · They raise the risk of confusion, falls and fractures
Why this is the answer
Older people are more sensitive to benzodiazepines and often eliminate them more slowly. Sedation, unsteadiness and confusion raise the risk of falls and fractures.
Answer
A · They raise the risk of confusion, falls and fractures
12.Pharmacology
Answer: A · Low TPMT activity causes toxic levels and marrow suppression
Why this is the answer
Thiopurine methyltransferase helps inactivate azathioprine and mercaptopurine. People with low or absent TPMT activity need much lower doses or another drug to avoid life-threatening myelosuppression.
Answer
A · Low TPMT activity causes toxic levels and marrow suppression
13.Med-surg: cardiovascular & respiratory
Answer: C · It suggests tissues are short of oxygen and using anaerobic metabolism
Why this is the answer
When tissues are poorly perfused, cells switch to anaerobic metabolism and produce lactate. A raised lactate is a marker of tissue hypoperfusion and severity in sepsis and shock. Repeated measurements show whether treatment is working.
Answer
C · It suggests tissues are short of oxygen and using anaerobic metabolism
14.Med-surg: cardiovascular & respiratory
Answer: C · The patient is tiring and respiratory failure may follow
Why this is the answer
Early in an attack, hyperventilation lowers PaCO₂. A normal or rising PaCO₂ in a breathless, tiring patient means ventilation is failing and is a life-threatening feature. Urgent senior and critical care review is needed.
Answer
C · The patient is tiring and respiratory failure may follow
15.Med-surg: neuro, endocrine & renal
Answer: C · Bacteria that convert nitrate are present
Why this is the answer
Many urinary pathogens convert dietary nitrate to nitrite, so a positive nitrite test supports a bacterial UTI. A negative result does not rule infection out. Leucocytes on the dipstick show white cells.
Answer
C · Bacteria that convert nitrate are present
16.Med-surg: neuro, endocrine & renal
Answer: C · Carbamazepine can cause hyponatraemia through an SIADH-like effect
Why this is the answer
Carbamazepine (and oxcarbazepine) can increase the effect of ADH, leading to water retention and hyponatraemia. Severe hyponatraemia causes confusion and seizures. The drug and sodium need urgent medical review.
Answer
C · Carbamazepine can cause hyponatraemia through an SIADH-like effect
17.Med-surg: GI, perioperative & oncology
Answer: A · Constipation
Why this is the answer
Common side effects of ondansetron include constipation and headache. It can also prolong the QT interval, so caution is needed with other QT-prolonging drugs and electrolyte imbalance.
Answer
A · Constipation
18.Med-surg: GI, perioperative & oncology
Answer: A · Residual neuromuscular blockade
Why this is the answer
Remaining muscle relaxant causes weakness, poor head lift and shallow breathing in an awake patient. The nurse supports breathing, gives oxygen and calls the anaesthetist, who may give a reversal agent.
Answer
A · Residual neuromuscular blockade
19.Maternity & obstetric nursing
Answer: A · Facial nerve palsy
Why this is the answer
Pressure from forceps blades on the facial nerve can cause temporary facial palsy, with asymmetry when the baby cries. It usually resolves within weeks.
Answer
A · Facial nerve palsy
20.Maternity & obstetric nursing
Answer: D · Acknowledge her grief; tests may find a cause
Why this is the answer
The nurse acknowledges her grief, avoids blame and explains that investigations such as a post-mortem and placental examination may help find a cause, although often none is found.
Answer
D · Acknowledge her grief; tests may find a cause
21.Pediatric nursing
Answer: D · A child with severe immune suppression, for example during chemotherapy
Why this is the answer
Live vaccines are generally contraindicated in severe immune suppression and in pregnancy. Mild illness and antibiotic treatment are not contraindications.
Answer
D · A child with severe immune suppression, for example during chemotherapy
22.Pediatric nursing
Answer: D · To keep the ductus arteriosus open so that the two circulations can mix
Why this is the answer
In duct-dependent lesions such as transposition of the great arteries, the open ductus lets blood mix between the circulations until surgery. Prostaglandin E1 keeps the duct open; the baby is monitored for apnoea.
Answer
D · To keep the ductus arteriosus open so that the two circulations can mix
23.Mental health nursing
Answer: C · A trained professional interpreter
Why this is the answer
Professional interpreters translate accurately and keep confidentiality. Family members, especially children, may filter information and should not interpret sensitive assessments such as those about suicide or abuse.
Answer
C · A trained professional interpreter
24.Mental health nursing
Answer: B · Hold the serotonergic medicines and inform the prescriber urgently
Why this is the answer
These signs suggest serotonin syndrome. The first steps are to stop the serotonergic drugs and get urgent medical review; supportive care and monitoring follow, and severe cases need intensive care.
Answer
B · Hold the serotonergic medicines and inform the prescriber urgently
25.Nursing math & unit conversions
Answer: 2:40 PM
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Convert the hour
14 − 12 = 2 → PM
Answer
2:40 PM
Answer
2:40 PM
26.Nursing math & unit conversions
Answer: D = 50 mcg/min
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 3 mg/h × (1000 mcg/1 mg) × (1 h/60 min)
Calculate
D = 3000/60 = 50 mcg/min
Answer
D = 50 mcg/min
27.Dosage calculations
Answer: D = 135 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.
Dose
7.5·18 = 135 mg
Answer
D = 135 mg
28.Dosage calculations
Answer: R = 7.813 mL/h
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration
40000/250 = 160 units/mL
Pump rate
R = 1250/160 = 7.813 mL/h
Answer
R = 7.813 mL/h
29.IV infusion rates
Answer: R = 94 mL/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.
Original rate
1000/12 = 83.33 mL/h
New rate
R = 470/5 = 94 mL/h
Answer
R = 94 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: Δ = 26 %
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.
Original rate
500/12 = 41.67 mL/h
New rate
R = 210/4 = 52.5 mL/h
Percentage change
Δ = (52.5 − 41.67)/41.67·100% = 26%
Answer
Δ = 26%
This is more than a 25% increase: most hospitals require you to contact the prescriber instead of catching up, and to assess the patient for fluid overload.
31.Pediatric & critical-care dosing
Answer: R = 14 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
14·50 = 700 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 700/50 = 14 mL/h
Answer
R = 14 mL/h
32.Pediatric & critical-care dosing
Answer: R = 22.1 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
800 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
10·59 = 590 mcg/min
590·60 = 35400 mcg/h
Pump rate
R = 35400/1600 = 22.13 ≈ 22.1 mL/h
Answer
R = 22.1 mL/h
33.IV fluids & fluid balance
Answer: B = 600 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 + 150 = 350 mL
ice chips: 200/2 = 100 mL
IV infusion: 75·12 = 900 mL
IV antibiotic: 1·100 = 100 mL
total intake = 1450 mL
Total output
300 + 250 + 300 = 850 mL
Balance
B = 1450 − 850 = 600 mL
Answer
B = 600 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 875 mL
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Elapsed time
07:30 → 10:00 = 2.5 h
Volume infused
50·2.5 = 125 mL
Volume left
V = 1000 − 125 = 875 mL
Answer
V = 875 mL
35.Clinical assessment scores
Answer: MFS = 100
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: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: yes → 20
gait: weak → 10
mental status: overestimates or forgets limits → 15
Add
Morse total = 25 + 15 + 15 + 20 + 10 + 15 = 100
Answer
MFS = 100
36.Clinical assessment scores
Answer: low
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 24/min → 2
SpO₂ 99% → 0
on air → 0
SBP 136 mmHg → 0
HR 104/min → 1
alert (A) → 0
T 36.3 °C → 0
Total and red scores
NEWS2 = 2 + 0 + 0 + 0 + 1 + 0 + 0 = 3
No parameter scores 3.
Risk group
low
Answer
low
37.Arterial blood gas interpretation
Answer: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.30: acidaemia (below 7.35)
PaCO₂ 51 mmHg: high (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: delta ratio = 1.214
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 = 146 − (107 + 10) = 29
Delta ratio
(29 − 12)/(24 − 10) = 17/14 = 1.214
Answer
delta ratio = 1.214
Between 1 and 2: a pure high anion gap acidosis.
39.ECG rhythm strip interpretation
Answer: sinus rhythm with sinus arrest
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. Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Five steps
1. Rate: 6 QRS complexes in 6 s, × 10 = 60 per minute.
2. Rhythm: regular (R–R 0.84 s) except for one pause of 1.92 s, which is not a whole number of P–P cycles.
3. P waves: upright, one before every QRS; no P wave at all during the pause.
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 rhythm with sinus arrest
Answer
sinus rhythm with sinus arrest
40.ECG rhythm strip interpretation
Answer: third-degree (complete) AV block
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.
Five steps
1. Rate: R–R = 48 small boxes, 1500 ÷ 48 ≈ 31 per minute.
2. Rhythm: R–R regular (1.92 s) and P–P regular (0.80 s), but the two are independent.
3. P waves: upright and regular at 75 per minute, but not linked to the QRS complexes; some hide in a QRS or a T wave.
4. PR interval: varies from beat to beat; there is no fixed relation.
5. QRS: 0.14 s, wide (0.12 s or more).
Interpretation
third-degree (complete) AV block
Answer
third-degree (complete) AV block
Type II and third-degree blocks are the ones that can suddenly progress, so textbooks rank them as more serious than type I.
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