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 patient goal is written in a SMART way?
AThe patient will improve mobility
BThe patient will try to eat more
CThe patient will feel better soon
DThe patient will walk 20 metres with a frame by Friday
2.Nursing fundamentalsHard
A healthcare assistant (nursing assistant) has recorded a blood pressure of 82/50 mmHg during routine observations but did not report it. What should the registered nurse do first?
ARepeat the observations at the next routine time
BAssess the patient straight away
CTalk to the healthcare assistant about reporting
DComplete an incident report
3.Infection control & patient safetyMedium
A patient is on seizure precautions. Which equipment should be ready at the bedside?
ARestraints ready for all four limbs
BWorking suction and oxygen equipment
CAn ice pack to place on the forehead
DA tongue blade to put between the teeth
4.Infection control & patient safetyHard
A nurse has a needlestick from a patient known to have hepatitis C. Which statement about management is correct?
AThe hepatitis C vaccine series is started at once, with a booster dose six months later
BNo follow-up is needed because hepatitis C does not spread by needles
CHepatitis C immune globulin is given within 24 hours, followed by a booster dose
DThere is no preventive drug, so baseline and follow-up testing are done to detect infection early
5.Prioritization & delegationMedium
A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?
ARising blood glucose levels
BWeight loss from too much appetite
CHair growth and skin color
DThoughts of suicide or self-harm
6.Prioritization & delegationHard
Which task is most appropriate for the RN to do personally rather than delegate to a nursing assistant?
AGetting a patient out of bed for the first time after surgery
BTaking a stable patient for a walk in the corridor on the third day after surgery
CHelping a patient with oral care
DWeighing a patient with heart failure each morning
7.Clinical nursingMedium
How does ulcerative colitis differ from Crohn's disease?
AUlcerative colitis affects only the colon, continuously from the rectum
BUlcerative colitis can affect any part of the gut from mouth to anus
CUlcerative colitis typically causes patchy "skip" lesions
DUlcerative colitis always affects the full thickness of the bowel wall
8.Clinical nursingHard
During CPR for asystole, when should adrenaline (epinephrine) be given according to standard adult guidelines?
AOnly once the patient has a pulse again
BAs soon as IV or IO access is obtained, then every 3–5 minutes
CNever, because asystole is not treated with drugs
DOnly after three shocks have been delivered by the defibrillator
9.Lab values & electrolytesMedium
A patient has a platelet count of 18 × 10³/µL. Which nursing measure is appropriate?
ASoft toothbrush, electric razor and no intramuscular injections
BEncourage flossing twice daily and shaving with a sharp razor blade
CTake temperatures rectally every four hours for accuracy
DGive the prescribed aspirin when the patient has a headache
10.Lab values & electrolytesHard
A patient stopped long-term prednisone suddenly a week ago. Now: blood pressure 78/46 mm Hg, sodium 128 mEq/L, potassium 4.6 mEq/L, glucose 58 mg/dL (3.2 mmol/L). Which condition is most likely?
AAcute adrenal insufficiency (adrenal crisis)
BCushing syndrome from steroid excess
CSyndrome of inappropriate ADH (SIADH)
DPrimary hyperaldosteronism (Conn syndrome)
11.PharmacologyMedium
Which patient should usually not use the combined oral contraceptive pill?
AA 38-year-old woman who smokes 20 cigarettes a day
BA 22-year-old non-smoker with acne
CA 30-year-old non-smoker with no medical problems
DA 25-year-old woman with heavy periods
12.PharmacologyHard
How does levonorgestrel emergency contraception mainly work?
AIt kills sperm in the vagina
BIt delays or prevents ovulation
CIt ends an established pregnancy
DIt causes an immediate period
13.Med-surg: cardiovascular & respiratoryMedium
Suspected pulmonary TB is being investigated. How are sputum samples usually collected?
AOne sample of saliva collected at any time of the day
BSeveral samples, ideally including early-morning sputum
CA swab from the nose only
DA single sample after the first week of treatment
14.Med-surg: cardiovascular & respiratoryHard
A patient on warfarin for atrial fibrillation has an INR of 8.5 but no bleeding. What is the most likely management?
AContinue the usual dose and recheck the INR in a month
BGive IV protamine sulfate immediately to reverse it
CGive prothrombin complex concentrate and a blood transfusion
DWithhold warfarin, inform the prescriber and recheck the INR soon
15.Med-surg: neuro, endocrine & renalMedium
Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?
ATo stop the drug from irritating an empty stomach later on
BTo reduce stomach acid so the food is digested better
CTo improve the strength of chewing and swallowing at mealtimes
DTo lower the blood glucose rise after eating a meal
16.Med-surg: neuro, endocrine & renalHard
Four patients had a minor head injury with no loss of consciousness and a GCS of 15. Which one most needs a CT scan of the head?
AA 25-year-old with a small scalp graze after a fall
BA 78-year-old who takes warfarin for atrial fibrillation
CA 40-year-old with a mild headache that is improving
DA 30-year-old who bumped their head on a cupboard door
17.Med-surg: GI, perioperative & oncologyMedium
For which stoma can colostomy irrigation be considered?
AAn established descending or sigmoid colostomy
BA new ileostomy in the first week
CAny stoma that has liquid or very loose output
DAn ileal conduit draining urine
18.Med-surg: GI, perioperative & oncologyHard
A patient with long-standing chronic pancreatitis now has weight loss, thirst and passing large volumes of urine. What should the nurse check first?
ACapillary blood glucose
BPeak expiratory flow
CAbdominal girth
DSerum amylase level
19.Maternity & obstetric nursingMedium
A woman in labour has severe back pain with each contraction. The fetus is in an occiput posterior position. Which measure is most likely to help?
AHolding her breath and pushing with each contraction
BSacral counterpressure and a hands-and-knees position
CLying flat on her back with her legs raised
DAvoiding movement until full dilation
20.Maternity & obstetric nursingHard
Why does the foramen ovale close soon after birth?
AProstaglandin levels rise in the newborn's blood
BLeft atrial pressure rises above right atrial pressure
CThe umbilical vein carries more blood to the heart
DBlood flow to the lungs decreases after birth
21.Pediatric nursingMedium
A 5-week-old baby has forceful (projectile) vomiting after every feed and seems hungry afterwards. What is the likely cause?
AGastro-oesophageal reflux that is normal for age
BIntussusception
CPyloric stenosis
DHirschsprung disease
22.Pediatric nursingHard
A 2-year-old has had three febrile urinary tract infections. Which underlying condition should be considered?
ANephrotic syndrome
BTesticular torsion on both sides
CVesicoureteral reflux
DHypospadias
23.Mental health nursingMedium
What is the CIWA-Ar scale used for?
AMeasuring the risk of falls in hospital
BScreening for dementia in older adults
CRating the severity of alcohol withdrawal to guide treatment
DMeasuring the depth of sedation in patients on a ventilator in intensive care
24.Mental health nursingHard
Which patient should the nurse check first?
AA patient with OCD who is late for breakfast because of a long washing ritual in the bathroom
BA patient with schizophrenia who wants a cigarette break in the garden
CA patient given IM haloperidol and lorazepam 30 minutes ago who is hard to rouse, breathing 8/min
DA patient with depression who is asking for help to phone his mother
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 8:10 PM. Which entry is the same time on the 24-hour clock? Click it.
8:10 PM
119:10
221:10
308:10
420:10
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads ½ tsp of an oral suspension every 12 hours for 14 days. The suspension comes in 50 mL bottles. Using 1 tsp = 5 mL, how many whole bottles N must be supplied so the course is complete?
½ tspevery 12 hours14 days50 mL1 tsp = 5 mL
N =
27.Dosage calculationsMedium
A child weighing 18 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?
18 kg10 mg/kg25 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 320 micrograms. The ampoule contains 1 mg/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
320 mcg1 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 20 gtt/mL. Find the drip rate R in drops per minute.
150 mL/h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 500 mg of a drug in 50 mL and runs at 15 mL/h. How many milligrams per hour D does the patient receive?
500 mg/50 mL15 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 100 mL. The order is 7 units/h. Find the pump rate R in mL/h. Round to one decimal place.
100 units/100 mL7 units/h
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 400 mg in 250 mL. The order is 2 mcg/kg/min for a patient who weighs 85 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL2 mcg/kg/min85 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL. Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 50 mL/h. At 12:30, 50 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL50 mL infused50 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 56/min and a blood pressure of 85/55 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 56/minBP 85/55 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 16/min, SpO₂ 98% on room air, blood pressure 124/74 mmHg, pulse 88/min, newly confused, temperature 36.0 °C. Which clinical risk group does the patient fall into? Click it.
RR 16SpO₂ 98%airSBP 124HR 88CT 36.0 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 29 mmHg (3.9 kPa). Use the rule that in chronic respiratory alkalosis HCO₃⁻ falls by 5 mmol/L for every 10 mmHg that PaCO₂ is below 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a respiratory acidosis: pH 7.22, PaCO₂ 68 mmHg (9.1 kPa), HCO₃⁻ 27 mmol/L. Use the rules ‘HCO₃⁻ rises 1 mmol/L per 10 mmHg (acute) or 3.5 mmol/L per 10 mmHg (chronic)’ to classify it. Click your answer.
pH 7.22PaCO₂ 68 mmHg (9.1 kPa)HCO₃⁻ 27 mmol/L
1acute
2chronic
3acute on chronic
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
1first-degree AV block
2ventricular bigeminy
3atrial fibrillation
4sinus rhythm with PVCs
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
1dual-chamber (AV) paced rhythm
2idioventricular rhythm
3third-degree (complete) AV block
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: D · The patient will walk 20 metres with a frame by Friday
Why this is the answer
A SMART goal states exactly what is expected, how it will be measured and by when. "Walk 20 metres with a frame by Friday" can be checked; "feel better" cannot.
Answer
D · The patient will walk 20 metres with a frame by Friday
2.Nursing fundamentals
Answer: B · Assess the patient straight away
Why this is the answer
A low blood pressure may mean deterioration, so the nurse assesses the patient at once and escalates if needed. Feedback to the assistant and reporting follow afterwards.
Answer
B · Assess the patient straight away
3.Infection control & patient safety
Answer: B · Working suction and oxygen equipment
Why this is the answer
Suction and oxygen are kept ready to manage secretions and support breathing during or after a seizure. Nothing is put in the mouth, and restraints are not used because they can cause injury.
Answer
B · Working suction and oxygen equipment
4.Infection control & patient safety
Answer: D · There is no preventive drug, so baseline and follow-up testing are done to detect infection early
Why this is the answer
There is no vaccine or post-exposure prophylaxis for hepatitis C. The exposure is reported, baseline tests are taken and follow-up testing identifies infection early, because effective treatment is available.
Answer
D · There is no preventive drug, so baseline and follow-up testing are done to detect infection early
5.Prioritization & delegation
Answer: D · Thoughts of suicide or self-harm
Why this is the answer
In the early weeks of antidepressant treatment, especially in young people, suicidal thoughts may increase. Patients and families are taught to report them at once.
Answer
D · Thoughts of suicide or self-harm
6.Prioritization & delegation
Answer: A · Getting a patient out of bed for the first time after surgery
Why this is the answer
The first time out of bed after surgery the patient may faint or show other unexpected responses, so the RN usually assesses the patient during it. Later walks with a stable patient, daily weights and oral care are routine tasks.
Answer
A · Getting a patient out of bed for the first time after surgery
7.Clinical nursing
Answer: A · Ulcerative colitis affects only the colon, continuously from the rectum
Why this is the answer
Ulcerative colitis involves the mucosa of the colon, spreading continuously from the rectum. Crohn's disease can affect any part of the GI tract, is transmural and has skip lesions.
Answer
A · Ulcerative colitis affects only the colon, continuously from the rectum
8.Clinical nursing
Answer: B · As soon as IV or IO access is obtained, then every 3–5 minutes
Why this is the answer
In non-shockable rhythms, adrenaline is given as soon as possible and repeated every 3–5 minutes while CPR continues. In shockable rhythms it is given after the third shock in UK/European guidelines (after the second shock in AHA guidelines).
Answer
B · As soon as IV or IO access is obtained, then every 3–5 minutes
9.Lab values & electrolytes
Answer: A · Soft toothbrush, electric razor and no intramuscular injections
Why this is the answer
Severe thrombocytopenia causes bleeding from minor trauma. Bleeding precautions include soft toothbrushes, electric razors, no IM injections or rectal procedures, and avoiding aspirin and NSAIDs.Checked against:Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Platelet Tests · MedlinePlus (NIH) (2024)
Answer
A · Soft toothbrush, electric razor and no intramuscular injections
10.Lab values & electrolytes
Answer: A · Acute adrenal insufficiency (adrenal crisis)
Why this is the answer
Long-term glucocorticoids suppress the body's own cortisol production; stopping them suddenly can cause adrenal crisis. Lack of cortisol causes hypotension, hyponatremia and hypoglycemia. Aldosterone is usually still made, so potassium is often normal; high potassium suggests primary adrenal failure. Treatment is IV hydrocortisone and fluids as prescribed.
Answer
A · Acute adrenal insufficiency (adrenal crisis)
11.Pharmacology
Answer: A · A 38-year-old woman who smokes 20 cigarettes a day
Why this is the answer
Smoking over the age of 35 greatly increases the risk of myocardial infarction and stroke with combined hormonal contraception. Progestogen-only or non-hormonal methods are preferred.
Answer
A · A 38-year-old woman who smokes 20 cigarettes a day
12.Pharmacology
Answer: B · It delays or prevents ovulation
Why this is the answer
Levonorgestrel emergency contraception mainly prevents or delays ovulation and does not disrupt an implanted pregnancy. Its effectiveness falls the longer it is delayed after unprotected sex.
Answer
B · It delays or prevents ovulation
13.Med-surg: cardiovascular & respiratory
Answer: B · Several samples, ideally including early-morning sputum
Why this is the answer
Usually three sputum samples, including an early-morning sample, are sent for smear microscopy, culture and molecular testing. Deep coughed sputum, not saliva, is needed. Samples are collected before treatment where possible and in a way that limits exposure to others.
Answer
B · Several samples, ideally including early-morning sputum
14.Med-surg: cardiovascular & respiratory
Answer: D · Withhold warfarin, inform the prescriber and recheck the INR soon
Why this is the answer
A very high INR without bleeding is usually managed by withholding warfarin, informing the prescriber and repeating the INR. Low-dose oral vitamin K may also be prescribed depending on the INR and local protocol (UK guidance gives it above an INR of 8; US guidance mainly above 10 or with high bleeding risk). Prothrombin complex concentrate and IV vitamin K are used for major bleeding. Protamine reverses heparin. The reason for the rise (new drugs, illness, diet) should be explored.
Answer
D · Withhold warfarin, inform the prescriber and recheck the INR soon
15.Med-surg: neuro, endocrine & renal
Answer: C · To improve the strength of chewing and swallowing at mealtimes
Why this is the answer
Pyridostigmine inhibits acetylcholinesterase, so more acetylcholine is available at the neuromuscular junction. Timing it before meals gives the best muscle strength for chewing and swallowing, which lowers the risk of aspiration.
Answer
C · To improve the strength of chewing and swallowing at mealtimes
16.Med-surg: neuro, endocrine & renal
Answer: B · A 78-year-old who takes warfarin for atrial fibrillation
Why this is the answer
Anticoagulation greatly increases the risk of an intracranial bleed after even a minor head injury, and older age adds to the risk. These patients have a low threshold for a CT scan, even when they appear well.
Answer
B · A 78-year-old who takes warfarin for atrial fibrillation
17.Med-surg: GI, perioperative & oncology
Answer: A · An established descending or sigmoid colostomy
Why this is the answer
Irrigation instils water into a sigmoid or descending colostomy to empty the bowel at set times. It is not used for ileostomies or urostomies and needs specialist teaching.
Answer
A · An established descending or sigmoid colostomy
18.Med-surg: GI, perioperative & oncology
Answer: A · Capillary blood glucose
Why this is the answer
Destruction of islet cells in chronic pancreatitis can cause diabetes (type 3c). Thirst, polyuria and weight loss suggest hyperglycaemia, which is checked straight away.
Answer
A · Capillary blood glucose
19.Maternity & obstetric nursing
Answer: B · Sacral counterpressure and a hands-and-knees position
Why this is the answer
In occiput posterior positions the fetal head presses on the sacrum. Counterpressure on the lower back and positions such as hands-and-knees or leaning forward ease pain and may help the head rotate.
Answer
B · Sacral counterpressure and a hands-and-knees position
20.Maternity & obstetric nursing
Answer: B · Left atrial pressure rises above right atrial pressure
Why this is the answer
With the first breaths, pulmonary resistance falls and more blood returns to the left atrium, while cord clamping lowers right-sided pressure. The higher left atrial pressure pushes the flap of the foramen ovale shut.
Answer
B · Left atrial pressure rises above right atrial pressure
21.Pediatric nursing
Answer: C · Pyloric stenosis
Why this is the answer
Pyloric stenosis typically presents at 2–8 weeks with projectile, non-bilious vomiting, hunger after vomiting, weight loss and sometimes a palpable olive-shaped mass.
Answer
C · Pyloric stenosis
22.Pediatric nursing
Answer: C · Vesicoureteral reflux
Why this is the answer
Vesicoureteral reflux allows urine to flow back from the bladder into the ureters and kidneys, causing recurrent UTIs and possible kidney scarring. Children with repeated febrile UTIs are investigated with imaging.
Answer
C · Vesicoureteral reflux
23.Mental health nursing
Answer: C · Rating the severity of alcohol withdrawal to guide treatment
Why this is the answer
The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar), scores withdrawal signs and symptoms. Repeated scores guide symptom-triggered benzodiazepine treatment.
Answer
C · Rating the severity of alcohol withdrawal to guide treatment
24.Mental health nursing
Answer: C · A patient given IM haloperidol and lorazepam 30 minutes ago who is hard to rouse, breathing 8/min
Why this is the answer
Over-sedation with respiratory depression after rapid tranquillisation is a medical emergency. Airway, breathing and vital signs are checked immediately, and help is called.
Answer
C · A patient given IM haloperidol and lorazepam 30 minutes ago who is hard to rouse, breathing 8/min
25.Nursing math & unit conversions
Answer: 20:10
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
8 PM → 8 + 12 = 20
Answer
20:10
Answer
20:10
26.Nursing math & unit conversions
Answer: N = 2
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.
Total volume
2.5 mL × 2 × 14 = 70 mL
Bottles
70/50 = 1.4 → N = 2
Answer
N = 2
27.Dosage calculations
Answer: V = 7.2 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 = 10·18 = 180 mg
Volume
V = 180/25 = 7.2 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 7.2 mL
28.Dosage calculations
Answer: V = 0.32 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
1 mg/mL = 1000 mcg/mL
Volume
V = 320/1000 = 0.32 mL
Answer
V = 0.32 mL
29.IV infusion rates
Answer: R = 50 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 = 2.5·20 = 50 gtt/min
Answer
R = 50 gtt/min
30.IV infusion rates
Answer: D = 150 mg/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.
Concentration
500/50 = 10 mg/mL
Dose rate
D = 10·15 = 150 mg/h
Answer
D = 150 mg/h
31.Pediatric & critical-care dosing
Answer: R = 7 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.
Concentration
100/100 = 1 units/mL
Pump rate
R = 7/1 = 7 mL/h
Answer
R = 7 mL/h
32.Pediatric & critical-care dosing
Answer: R = 6.4 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
400 mg = 400 000 mcg
400 000/250 = 1600 mcg/mL
Dose per minute and per hour
2·85 = 170 mcg/min
170·60 = 10200 mcg/h
Pump rate
R = 10200/1600 = 6.375 ≈ 6.4 mL/h
Answer
R = 6.4 mL/h
33.IV fluids & fluid balance
Answer: I = 1140 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: 100 + 200 + 120 = 420 mL
ice chips: 240/2 = 120 mL
IV infusion: 50·8 = 400 mL
IV antibiotic: 2·100 = 200 mL
I = 1140 mL
Answer
I = 1140 mL
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
500 − 50 = 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 21:30.
35.Clinical assessment scores
Answer: SI = 0.66
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Shock index
SI = 56/85 = 0.6588 ≈ 0.66
Answer
SI = 0.66
Within or below the usual 0.5–0.7.
36.Clinical assessment scores
Answer: low–medium
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 16/min → 0
SpO₂ 98% → 0
on air → 0
SBP 124 mmHg → 0
HR 88/min → 0
newly confused (C) → 3
T 36.0 °C → 1
Total and red scores
NEWS2 = 0 + 0 + 0 + 0 + 0 + 3 + 1 = 4
At least one parameter scores 3.
Risk group
low–medium
Answer
low–medium
A single score of 3 needs an urgent review even when the total is low.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 18.5 mmol/L
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.
Change in PaCO₂
|29 − 40| = 11 mmHg → 1.1 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 − 5·1.1 = 18.5 mmol/L
Answer
HCO₃⁻ = 18.5 mmol/L
38.Arterial blood gas interpretation
Answer: acute
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected HCO₃⁻
acute: 24 + 1·2.8 = 26.8 mmol/L
chronic: 24 + 3.5·2.8 = 33.8 mmol/L
Compare
measured: 27 mmol/L → acute
Answer
acute
39.ECG rhythm strip interpretation
Answer: sinus rhythm with PVCs
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: regular (0.84 s) except for the early beats and the pause after each of them.
3. P waves: upright before every narrow QRS; none before the early wide beats.
4. PR interval: 0.16 s, constant, within 0.12–0.20 s.
5. QRS: 0.06 s in the sinus beats; the early beats are wide (0.16 s) and bizarre, with the T wave pointing the other way.
Interpretation
sinus rhythm with PVCs
Answer
sinus rhythm with PVCs
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 = 22 small boxes, 1500 ÷ 22 ≈ 68 per minute.
2. Rhythm: regular, every R–R is 0.88 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.20 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.
This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.