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 measures help prevent constipation in hospital patients?
ALimiting fluids and staying in bed to rest the bowel
BAvoiding fruit and vegetables
CHolding in the urge to open the bowels
DAdequate fluids, dietary fibre and mobility
2.Nursing fundamentalsHard
While counting an apical pulse, the nurse finds the rhythm is irregularly irregular and the radial rate is lower than the apical rate. Which rhythm is most likely?
ASinus tachycardia
BNormal sinus rhythm
CAtrial fibrillation
DSinus bradycardia
3.Infection control & patient safetyMedium
A portable x-ray is taken at the bedside. Which action protects the nurse?
AStay close to the patient to keep them still without protection
BStand next to the patient and hold the film without protection
CLook directly at the x-ray tube during the exposure to check its position
DStep away from the patient or wear a lead apron during the exposure
4.Infection control & patient safetyHard
A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?
ANo, because reporting near misses only blames the pharmacy staff for nothing
BYes, near misses are reported so system weaknesses can be fixed
CNo, because the patient was not harmed
DOnly if the same error happens three times
5.Prioritization & delegationMedium
Which practice makes a shift handover safest?
AHanding over only the patients who had problems during the shift
BLeaving a sticky note on the computer screen for the next nurse
CA quick chat in the corridor with no notes taken
DA structured format, such as SBAR, with time for questions
6.Prioritization & delegationHard
A patient with diabetes is sweaty and confused, and no glucose meter is available. The patient can swallow. What should the nurse do?
AAsk the patient to lie down and sleep it off
BGive a dose of rapid-acting insulin in case the glucose is high
CTreat for hypoglycemia with fast-acting oral carbohydrate
DWithhold all food and fluids until a meter is found
7.Clinical nursingMedium
Why is oxygen often humidified for a patient with a tracheostomy?
ADry oxygen causes high blood glucose
BHumidity is needed for the oxygen to work as a drug
CHumidification lowers the oxygen concentration to a safer level
DThe tube bypasses the nose, which normally warms and moistens air
8.Clinical nursingHard
Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?
AOral tablet dissolved under the tongue
BSubcutaneous injection into the upper arm
CIntramuscular injection into the anterolateral thigh
DIntravenous bolus given by the nurse without monitoring
9.Lab values & electrolytesMedium
A woman with hyperemesis gravidarum has vomited for 3 days. Which urine finding would the nurse expect?
AKetones
BRed cell casts
CBilirubin
DNitrites
10.Lab values & electrolytesHard
A patient taking apixaban asks why they do not need regular INR tests like their neighbor on warfarin. What is the best explanation?
AApixaban is monitored with an aPTT every day instead
BIts effect is predictable, so routine clotting tests are not needed
CApixaban does not actually thin the blood
DThe INR is checked secretly together with the other routine blood tests
11.PharmacologyMedium
Bethanechol may be used for non-obstructive urinary retention. How does it work?
AIt stimulates muscarinic receptors and contracts the bladder muscle
BIt blocks muscarinic receptors and relaxes the bladder wall muscle
CIt shrinks the prostate gland
DIt increases urine production in the kidney
12.PharmacologyHard
Which property makes a drug more likely to cross the blood–brain barrier?
ALarge molecular weight and strong protein binding
BHigh water solubility and strong ionisation
CPositive charge at physiological pH
DHigh lipid solubility and small size
13.Med-surg: cardiovascular & respiratoryMedium
Which laboratory test is used to adjust an unfractionated heparin infusion?
AaPTT (or anti-Xa level)
BINR (international normalised ratio)
CD-dimer level
DSerum fibrinogen level
14.Med-surg: cardiovascular & respiratoryHard
A patient on three blood pressure drugs still has high readings at every visit. What should the nurse check first?
AWhether the readings should be ignored
BWhether a fourth drug can be added at today's appointment
CWhether the patient is taking the medicines as prescribed
DWhether the patient needs surgery on the renal arteries
15.Med-surg: neuro, endocrine & renalMedium
A patient has taken metformin for many years and now has tingling feet and a low haemoglobin. Which blood test is most relevant?
AThyroid antibodies
BBlood alcohol level
CSerum amylase
DVitamin B12 level
16.Med-surg: neuro, endocrine & renalHard
A patient on warfarin starts levothyroxine for hypothyroidism. What should the nurse expect to monitor more closely?
AThe urine output, because it may stop
BThe blood glucose, because it may fall
CThe INR, because it may rise
DThe potassium, because it may rise
17.Med-surg: GI, perioperative & oncologyMedium
Which initial treatment is usual for symptomatic hypercalcaemia of malignancy?
AIV fluids followed by an IV bisphosphonate
BFluid restriction and a thiazide diuretic
COral calcium tablets and vitamin D
DA high-calcium diet with extra milk
18.Med-surg: GI, perioperative & oncologyHard
A patient taking oral capecitabine reports red, painful, peeling palms and soles. What should the nurse do?
AReassure that it is a sign of an unrelated allergy to washing powder
BAdvise hot soaks for the hands and feet
CTell the patient to take a double dose next time
DReport it; this is hand-foot syndrome and treatment may need changing
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?
AAscorbic acid (vitamin C)
BPhytomenadione (vitamin K)
CThiamine (vitamin B1)
DVitamin D
20.Maternity & obstetric nursingHard
At 7 weeks of pregnancy, a woman reports sudden severe pain on one side of the lower abdomen, pain in the shoulder tip and dizziness. What should the nurse suspect?
AA ruptured ectopic pregnancy with internal bleeding
BNormal round ligament pain caused by the growing uterus
CHyperemesis gravidarum
DBraxton Hicks contractions
21.Pediatric nursingMedium
Which factor can make a pulse oximeter reading inaccurate in a child?
AHaving eaten a meal in the last hour
BHolding a parent's hand during the reading
CLying on the back instead of sitting up
DCold hands, movement or a poorly fitting probe
22.Pediatric nursingHard
A large baby born to a mother with diabetes becomes jittery at 1 hour of age. What should the nurse check first?
AThe baby's blood group
BThe baby's serum bilirubin
CThe baby's blood glucose
DThe baby's haemoglobin
23.Mental health nursingMedium
What must a patient be told for consent to a new psychotropic medicine to be valid?
AThe expected benefits, the main risks and the alternatives, including no treatment
BOnly the benefits, so that the patient is not frightened by the side effects
COnly the name of the medicine and the time of day it will be given
DNothing at all, because psychiatric patients cannot give consent
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 paracetamol (acetaminophen) and check her again tomorrow
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 the next dose of venlafaxine as planned
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 9 lb 5 oz. Using 1 lb = 16 oz and 1 kg = 2.2 lb, find the weight m in kilograms. Round to two decimal places.
9 lb 5 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 21:50 and finishes at 06:55 the next morning (24-hour clock). How many minutes t did it run?
21:5006:55
t = min
27.Dosage calculationsMedium
A child weighing 23 kg is prescribed 10 mg/kg of a drug. The stock solution contains 25 mg/mL. Draw up the dose: what volume V do you give?
23 kg10 mg/kg25 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 420 units of a drug that comes as 1000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
420 units1000 units/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 40 gtt/min through a set of 20 gtt/mL. How many millilitres V does the patient receive in 2 hours?
40 gtt/min20 gtt/mL2 h
V = mL
30.IV infusion ratesHard
A drip runs at 25 gtt/min through a set of 60 gtt/mL. There are 200 mL left in the bag. How many hours t until it is empty?
25 gtt/min60 gtt/mL200 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 80 units/kg for a patient who weighs 70 kg. The vial contains 5 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg70 kg5 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 500 mg in 250 mL runs at 25 mL/h. The patient weighs 98 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
500 mg/250 mL25 mL/h98 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 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
jelly: 120 mLsoup: 200 mLtea: 150 mLIV infusion: 125 mL/h × 8 hIV antibiotic: 2 × 50 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 09:45 and runs by pump at 80 mL/h. How many mL V are left in the bag at 11:45?
1000 mL80 mL/h09:45 → 11:45
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 22/min, SpO₂ 99% on room air, blood pressure 102/62 mmHg, pulse 70/min, alert, temperature 36.5 °C. What is the NEWS2 total score?
RR 22SpO₂ 99%airSBP 102HR 70AT 36.5 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 103 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?
MAP 65 mmHgSBP 103 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.44, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 38 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.44PaCO₂ 58 mmHg (7.7 kPa)HCO₃⁻ 38 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 21% oxygen shows PaO₂ 81 mmHg (10.8 kPa) and PaCO₂ 34 mmHg (4.5 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
1second-degree AV block type II
2sinus arrhythmia
3sinus bradycardia
4sinus rhythm with sinus arrest
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
1second-degree AV block type I (Wenckebach)
2second-degree AV block type II
3atrial fibrillation
4first-degree AV block
3Solutions
1.Nursing fundamentals
Answer: D · Adequate fluids, dietary fibre and mobility
Why this is the answer
Fluids and fibre soften stools, and activity stimulates gut movement. Privacy and responding to the urge to defecate also help. Opioids and immobility increase the risk.
Answer
D · Adequate fluids, dietary fibre and mobility
2.Nursing fundamentals
Answer: C · Atrial fibrillation
Why this is the answer
Atrial fibrillation gives an irregularly irregular pulse, and some beats are too weak to be felt at the wrist, causing a pulse deficit. It should be reported and confirmed with an ECG.
Answer
C · Atrial fibrillation
3.Infection control & patient safety
Answer: D · Step away from the patient or wear a lead apron during the exposure
Why this is the answer
Radiation exposure falls quickly with distance. Staff leave the immediate area or wear a lead apron, and anyone who must hold a patient wears protective clothing.
Answer
D · Step away from the patient or wear a lead apron during the exposure
4.Infection control & patient safety
Answer: B · Yes, near misses are reported so system weaknesses can be fixed
Why this is the answer
Near misses show where errors can slip through and are reported in the same way as errors that reach the patient. Learning from them prevents future harm.
Answer
B · Yes, near misses are reported so system weaknesses can be fixed
5.Prioritization & delegation
Answer: D · A structured format, such as SBAR, with time for questions
Why this is the answer
Handover is a high-risk moment for errors. A structured format and the chance to ask questions help the next nurse understand each patient’s condition and priorities.
Answer
D · A structured format, such as SBAR, with time for questions
6.Prioritization & delegation
Answer: C · Treat for hypoglycemia with fast-acting oral carbohydrate
Why this is the answer
When in doubt, treat as hypoglycemia. A little sugar will not harm a patient with high glucose, but untreated hypoglycemia can cause brain injury within minutes, and insulin could be fatal.
Answer
C · Treat for hypoglycemia with fast-acting oral carbohydrate
7.Clinical nursing
Answer: D · The tube bypasses the nose, which normally warms and moistens air
Why this is the answer
The upper airway normally humidifies inspired air. Without it, secretions become thick and may block the tracheostomy tube, so humidification is used.
Answer
D · The tube bypasses the nose, which normally warms and moistens air
8.Clinical nursing
Answer: C · Intramuscular injection into the anterolateral thigh
Why this is the answer
IM adrenaline into the outer thigh is absorbed quickly and is the first-line route. IV adrenaline is reserved for experienced specialists with full monitoring because of the risk of arrhythmias.
Answer
C · Intramuscular injection into the anterolateral thigh
9.Lab values & electrolytes
Answer: A · Ketones
Why this is the answer
Prolonged vomiting and poor intake lead to fat breakdown and ketonuria, along with dehydration and electrolyte loss such as hypokalemia. Urine ketones help assess severity and response to IV fluids and antiemetics.Checked against:Ketones urine test · MedlinePlus (NIH) (2025)
Answer
A · Ketones
10.Lab values & electrolytes
Answer: B · Its effect is predictable, so routine clotting tests are not needed
Why this is the answer
Direct oral anticoagulants such as apixaban have predictable effects at fixed doses, so routine INR testing is not needed. Kidney and liver function, adherence and signs of bleeding are monitored, and the INR does not reliably measure their effect.
Answer
B · Its effect is predictable, so routine clotting tests are not needed
11.Pharmacology
Answer: A · It stimulates muscarinic receptors and contracts the bladder muscle
Why this is the answer
Bethanechol mimics acetylcholine at muscarinic receptors, contracting the detrusor muscle. It must not be used if there is mechanical obstruction to outflow.
Answer
A · It stimulates muscarinic receptors and contracts the bladder muscle
12.Pharmacology
Answer: D · High lipid solubility and small size
Why this is the answer
Small, lipophilic, non-ionised molecules diffuse across endothelial cell membranes. Charged or large, protein-bound drugs mostly stay out.
Answer
D · High lipid solubility and small size
13.Med-surg: cardiovascular & respiratory
Answer: A · aPTT (or anti-Xa level)
Why this is the answer
IV unfractionated heparin has a variable effect and is titrated to the aPTT (or anti-Xa level) according to the prescribed protocol. The platelet count is also checked to detect heparin-induced thrombocytopenia. D-dimer is used to help exclude thrombosis, not to monitor treatment.
Answer
A · aPTT (or anti-Xa level)
14.Med-surg: cardiovascular & respiratory
Answer: C · Whether the patient is taking the medicines as prescribed
Why this is the answer
Before labelling hypertension as resistant, adherence, measurement technique, white-coat effect and interacting substances (NSAIDs, decongestants, alcohol, liquorice) should be checked. Side effects, cost and complex regimens are common reasons for missed doses.
Answer
C · Whether the patient is taking the medicines as prescribed
15.Med-surg: neuro, endocrine & renal
Answer: D · Vitamin B12 level
Why this is the answer
Long-term metformin can lower vitamin B12 absorption, causing anaemia and neuropathy that may be mistaken for diabetic neuropathy. B12 levels are checked, especially when symptoms appear.
Answer
D · Vitamin B12 level
16.Med-surg: neuro, endocrine & renal
Answer: C · The INR, because it may rise
Why this is the answer
As thyroid function returns to normal, clotting factors are broken down faster, which increases the effect of warfarin. The INR is checked more often and the warfarin dose may need to be reduced.
Answer
C · The INR, because it may rise
17.Med-surg: GI, perioperative & oncology
Answer: A · IV fluids followed by an IV bisphosphonate
Why this is the answer
Hypercalcaemia causes polyuria and dehydration, so IV saline is given first, then a bisphosphonate such as zoledronic acid to reduce bone resorption. Calcium, kidney function and symptoms are monitored.
Answer
A · IV fluids followed by an IV bisphosphonate
18.Med-surg: GI, perioperative & oncology
Answer: D · Report it; this is hand-foot syndrome and treatment may need changing
Why this is the answer
Palmar-plantar erythrodysaesthesia (hand-foot syndrome) is common with capecitabine and fluorouracil. It is graded and may need a treatment break or dose reduction; emollients and avoiding heat and friction help.
Answer
D · Report it; this is hand-foot syndrome and treatment may need changing
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: A · A ruptured ectopic pregnancy with internal bleeding
Why this is the answer
One-sided pain, shoulder-tip pain and dizziness early in pregnancy suggest a ruptured ectopic pregnancy. It is an emergency: monitor vital signs, obtain IV access and get urgent medical help.
Answer
A · A ruptured ectopic pregnancy with internal bleeding
21.Pediatric nursing
Answer: D · Cold hands, movement or a poorly fitting probe
Why this is the answer
Pulse oximetry depends on a good pulsatile signal. Poor perfusion, cold extremities, movement, bright light and a wrong-sized probe can give false readings, so the reading is checked against the child's appearance and pulse.
Answer
D · Cold hands, movement or a poorly fitting probe
22.Pediatric nursing
Answer: C · The baby's blood glucose
Why this is the answer
Babies of mothers with diabetes produce extra insulin before birth, so after the cord is cut they are at high risk of hypoglycaemia. Jitteriness is a common sign, so blood glucose is checked straight away and the baby is fed or treated as per protocol.
Answer
C · The baby's blood glucose
23.Mental health nursing
Answer: A · The expected benefits, the main risks and the alternatives, including no treatment
Why this is the answer
Valid consent requires that the patient has capacity, has enough information about benefits, risks and alternatives, and decides voluntarily. A mental illness does not automatically remove capacity.
Answer
A · The expected benefits, the main risks and the alternatives, including no treatment
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: m = 4.23 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
5 oz/16 = 0.3125 lb
9 + 0.3125 = 9.313 lb
Pounds to kilograms
m = 9.313/2.2 = 4.233 ≈ 4.23 kg
Answer
m = 4.23 kg
26.Nursing math & unit conversions
Answer: t = 545 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
21:50 → 24:00 = 130 min
After midnight
00:00 → 06:55 = 415 min
Total
t = 130 + 415 = 545 min
Answer
t = 545 min
27.Dosage calculations
Answer: V = 9.2 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 = 10·23 = 230 mg
Volume
V = 230/25 = 9.2 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 9.2 mL
28.Dosage calculations
Answer: V = 0.42 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 420/1000 = 0.42 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.42 mL
29.IV infusion rates
Answer: V = 240 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
40·60/20 = 120 mL/h
Volume
V = 120·2 = 240 mL
Answer
V = 240 mL
30.IV infusion rates
Answer: t = 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
25·60/60 = 25 mL/h
Time left
t = 200/25 = 8 h
Answer
t = 8 h
31.Pediatric & critical-care dosing
Answer: V = 1.1 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
80·70 = 5 600 units
Volume
V = 5600/5000 = 1.12 ≈ 1.1 mL
Answer
V = 1.1 mL
32.Pediatric & critical-care dosing
Answer: D = 8.5 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
500 000/250 = 2000 mcg/mL
Micrograms per minute
25·2000 = 50000 mcg/h
50000/60 = 833.3 mcg/min
Per kilogram
D = 833.3/98 = 8.503 ≈ 8.5 mcg/kg/min
Answer
D = 8.5 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 1570 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.
Add the intake
oral: 120 + 200 + 150 = 470 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 2·50 = 100 mL
I = 1570 mL
Answer
I = 1570 mL
34.IV fluids & fluid balance
Answer: V = 840 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
09:45 → 11:45 = 2 h
Volume infused
80·2 = 160 mL
Volume left
V = 1000 − 160 = 840 mL
Answer
V = 840 mL
35.Clinical assessment scores
Answer: NEWS2 = 3
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 22/min → 2
SpO₂ 99% → 0
on air → 0
SBP 102 mmHg → 1
HR 70/min → 0
alert (A) → 0
T 36.5 °C → 0
Add
NEWS2 = 2 + 0 + 0 + 1 + 0 + 0 + 0 = 3
Answer
NEWS2 = 3
36.Clinical assessment scores
Answer: DBP = 46 mmHg
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.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·65 − 103)/2 = 92/2 = 46 mmHg
Answer
DBP = 46 mmHg
37.Arterial blood gas interpretation
Answer: fully compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.44: within 7.35–7.45
PaCO₂ 58 mmHg: high (35–45)
HCO₃⁻ 38 mmol/L: high (22–26)
Compensation
Clinically, also check the expected compensation: for a metabolic alkalosis PaCO₂ ≈ 0.7·HCO₃⁻ + 21 = 45.6–49.6 mmHg, so the measured 58 mmHg points to an additional respiratory acidosis (a mixed disorder). The answer above is the ROME exam classification.
fully compensated
Answer
fully compensated
38.Arterial blood gas interpretation
Answer: A–a gradient = 26.23 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. 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 0.96 s) except for one pause of 1.64 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: second-degree AV block type I (Wenckebach)
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: 4 QRS complexes in 6 s, × 10 = 40 per minute.
2. Rhythm: regularly irregular, the QRS complexes come in groups separated by a pause (group beating).
3. P waves: upright and regular (P–P 1.00 s, 60 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: lengthens 0.16 → 0.30 s, then a P wave is not conducted.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
second-degree AV block type I (Wenckebach)
Answer
second-degree AV block type I (Wenckebach)
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