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 position is recommended to reduce pressure on the sacrum and hips when a patient lies on their side?
ALying flat on the back with the head raised steeply
BSitting upright in bed for many hours
CA 30-degree tilt supported with pillows
DLying directly on the hip at 90 degrees
2.Nursing fundamentalsHard
An older patient who lives alone is ready to go home after a hip fracture but worries about washing and cooking. Which referral is most appropriate?
ASpeech and language therapy for a swallowing assessment
BPodiatry for nail care
COccupational therapy for a home assessment
DDietitian for a weight-loss plan
3.Infection control & patient safetyMedium
Which kitchen practice helps prevent scald burns in young children?
ALet the child stand on a chair beside the stove
BHold the child while drinking a hot drink
CLeave hot drinks at the edge of the table
DTurn pot handles toward the back of the stove
4.Infection control & patient safetyHard
During a urinary catheter insertion with sterile technique, the catheter tip touches the patient’s thigh. What should the nurse do?
AWipe the tip with an antiseptic and continue
BDiscard the catheter and use a new sterile one
CContinue, because the thigh was cleaned
DRinse the tip with sterile water and then continue
5.Prioritization & delegationMedium
Which nursing assistant task is appropriate for a patient two days after hip replacement?
AChecking the incision for redness, warmth and drainage
BHelping the patient into a chair, following the hip precautions
CTeaching the patient the hip precautions before discharge
DEvaluating whether the last dose of pain medication controlled the pain
6.Prioritization & delegationHard
In a disaster with very limited resources, a victim with severe burns over almost the whole body is tagged black. Which principle explains this decision?
ATreating victims in the order in which they arrive
BTreating the most severely injured person first
CTreating the youngest victims first
DDoing the greatest good for the greatest number
7.Clinical nursingMedium
Which of these is one of the "4 Hs", the reversible causes of cardiac arrest?
AHyperventilation
BHyperthyroidism
CHypoxia
DHypertension
8.Clinical nursingHard
A patient taking regular ibuprofen suddenly develops severe upper abdominal pain, a rigid abdomen and becomes tachycardic. What is most likely?
AIndigestion that will settle with antacids
BIrritable bowel syndrome
CConstipation
DA perforated peptic ulcer
9.Lab values & electrolytesMedium
A patient on carbamazepine becomes confused and has a headache. Which laboratory result would most likely explain this?
AA high serum calcium
BA low serum magnesium
CA low serum sodium
DA high serum potassium
10.Lab values & electrolytesHard
A patient admitted with heavy alcohol use and malnutrition has a glucose of 52 mg/dL (2.9 mmol/L) and low magnesium. Which prescribed treatment should be given before the IV glucose?
AIV thiamine
BIV insulin
COral iron
DIV potassium
11.PharmacologyMedium
Why is directly observed therapy (DOT) often used for tuberculosis?
APatients with TB cannot swallow tablets
BTB drugs must always be given intravenously in hospital
CThe drugs work only if a nurse is present
DTreatment lasts months, and missed doses cause resistance
12.PharmacologyHard
Newborns given chloramphenicol can develop "grey baby syndrome". What is the main reason?
AImmature glucuronidation in the liver lets the drug accumulate
BNewborns produce antibodies against the drug
CChloramphenicol is converted to vitamin K in neonates
DThe newborn kidney excretes the drug too quickly, so higher doses are given
13.Med-surg: cardiovascular & respiratoryMedium
Why is a non-selective beta-blocker such as propranolol usually avoided in a patient with asthma?
AIt can cause bronchospasm by blocking beta-2 receptors
BIt thickens airway mucus by drying the airways
CIt makes inhaled corticosteroids work too strongly
DIt raises the heart rate sharply during an acute asthma attack
14.Med-surg: cardiovascular & respiratoryHard
After six weeks of treatment for tuberculosis, a patient has nausea, dark urine and yellow eyes. What should the nurse do?
AWithhold the next doses and report urgently for liver tests
BDouble the isoniazid dose to clear the infection faster
CAdvise taking the tablets with an alcoholic drink to settle the stomach
DReassure the patient that the urine colour is due to rifampicin
15.Med-surg: neuro, endocrine & renalMedium
A patient taking a GLP-1 receptor agonist has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?
ANormal nausea from the drug
BAcute pancreatitis
CLow blood glucose
DA simple urinary tract infection
16.Med-surg: neuro, endocrine & renalHard
A patient with an acute stroke has a glucose of 15 mmol/L (270 mg/dL). They do not have known diabetes. What is appropriate?
AGive glucose gel to stabilise the level
BStop all IV fluids to lower the glucose
CReport it and monitor glucose, as it can worsen outcome
DIgnore it, because stress always raises glucose
17.Med-surg: GI, perioperative & oncologyMedium
Which nerve is at risk if the arm is poorly padded at the elbow during surgery?
AUlnar nerve
BFacial nerve
CSciatic nerve
DFemoral nerve
18.Med-surg: GI, perioperative & oncologyHard
A patient with gallstones has a temperature of 39 °C with rigors, jaundice and right upper abdominal pain. What should the nurse suspect?
AAcute hepatitis A
BUncomplicated reflux
CAscending cholangitis
DSimple biliary colic
19.Maternity & obstetric nursingMedium
Which finding points to postpartum depression rather than the baby blues?
ALow mood and loss of interest lasting more than 2 weeks and affecting daily life
BCrying spells and mood swings on day 3 that settle within a few days without treatment
CFeeling tired after a night with a crying baby
DFeeling emotional when visitors leave
20.Maternity & obstetric nursingHard
A breastfeeding mother asks whether she can have a progestin-only implant before discharge. Which reply is best?
AProgestin-only methods are compatible with breastfeeding
BAny hormonal contraception will stop her milk supply
CImplants contain oestrogen, which is safe in breastfeeding
DShe should wait until she stops breastfeeding before using any method
21.Pediatric nursingMedium
A newborn has a cephalohaematoma. What should the nurse monitor closely over the next days?
AJaundice, because the breakdown of the trapped blood adds to bilirubin
BHead circumference twice daily, because it signals hydrocephalus
CUrine colour, because the swelling causes kidney damage
DBlood pressure, because the swelling causes hypertension
22.Pediatric nursingHard
The nurse has taught the parents of a child with sickle cell disease. Which statement shows a need for further teaching?
A"We'll dress her warmly before she goes out in cold weather."
B"We'll learn how to feel her tummy for an enlarged spleen."
C"We'll call the hospital straight away if she has a fever."
D"In summer she can drink less so she doesn't need the toilet at school."
23.Mental health nursingMedium
The wife of a man with alcohol dependence organises her life around his drinking, hides it from others and neglects her own needs. What does this pattern suggest?
AEnabling by the healthcare team
BDelirium tremens
CCodependency
DLearned helplessness in the patient
24.Mental health nursingHard
A patient who used methamphetamine heavily for weeks stopped 2 days ago. He sleeps most of the day, is very low and says life is pointless. What is the priority?
AWake him often so that his sleep pattern returns to normal
BAssess his suicide risk
CGive a stimulant to relieve the low mood
DEncourage him to exercise hard to raise his energy
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 9 lb 10 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 10 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An order reads 5 mcg/kg/min for a patient who weighs 99 kg. Express the dose rate D in mg/h. Round to two decimal places.
5 mcg/kg/min99 kg
D = mg/h
27.Dosage calculationsMedium
An ampoule of epinephrine (adrenaline) is labelled 1:1000 (1 mg/mL). The prescription is 0.5 mg IM for anaphylaxis. What volume V do you draw up?
1:10000.5 mg
V = mL
28.Dosage calculationsHard
A patient is 132 cm tall and weighs 49 kg. The prescription is 250 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
132 cm49 kg250 mg/m²
D = mg
29.IV infusion ratesMedium
Infuse 1000 mL over 4 hours with a giving set of 15 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1000 mL4 h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 400 mg in 500 mL runs at 18 mL/h. How many micrograms per minute D does the patient receive?
400 mg/500 mL18 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 16 units/kg/h for a patient who weighs 68 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL16 units/kg/h68 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 250 mg in 250 mL runs at 5 mL/h. The patient weighs 58 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL5 mL/h58 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 patient weighs 54 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 07:30 at 120 mL/h. After 3 hours the rate is changed to 125 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL120 mL/h · 3 h125 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: no; gait: weak; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 121 kg and is 182 cm tall. Calculate the BMI and click the WHO weight category.
121 kg182 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.27, PaCO₂ 18 mmHg (2.4 kPa) and HCO₃⁻ 8 mmol/L. The primary disorder is metabolic acidosis. How far is it compensated? Click your answer.
pH 7.27PaCO₂ 18 mmHg (2.4 kPa)HCO₃⁻ 8 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 38 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 38 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
This lead II strip shows atrial flutter. How many flutter waves per QRS complex are there (the n of n:1 conduction)?
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
flutter waves per QRS =
40.ECG rhythm strip interpretationHard
Interpret this lead II strip. Which interpretation can you defend from this single 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
1second-degree AV block type I (Wenckebach)
22:1 AV block (type undetermined)
3second-degree AV block type II
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: C · A 30-degree tilt supported with pillows
Why this is the answer
The 30-degree tilt spreads weight away from the sacrum and greater trochanter. Raising the head of the bed steeply increases sliding and shear on the sacrum.
Answer
C · A 30-degree tilt supported with pillows
2.Nursing fundamentals
Answer: C · Occupational therapy for a home assessment
Why this is the answer
Occupational therapists assess how people manage daily activities and the home, and can arrange equipment such as perching stools and raised toilet seats.
Answer
C · Occupational therapy for a home assessment
3.Infection control & patient safety
Answer: D · Turn pot handles toward the back of the stove
Why this is the answer
Scalds from hot liquids are common childhood burns. Turning pot handles inward, using back burners and keeping hot drinks out of reach reduce the risk.
Answer
D · Turn pot handles toward the back of the stove
4.Infection control & patient safety
Answer: B · Discard the catheter and use a new sterile one
Why this is the answer
Once a sterile item touches a non-sterile surface, it is contaminated and is replaced. Inserting a contaminated catheter brings bacteria into the bladder and increases the risk of urinary tract infection.
Answer
B · Discard the catheter and use a new sterile one
5.Prioritization & delegation
Answer: B · Helping the patient into a chair, following the hip precautions
Why this is the answer
Helping a stable patient move, using precautions already set in the care plan, is a routine task. Inspecting the wound, teaching and evaluating pain relief need nursing assessment.
Answer
B · Helping the patient into a chair, following the hip precautions
6.Prioritization & delegation
Answer: D · Doing the greatest good for the greatest number
Why this is the answer
In a mass-casualty event, resources are used where they save the most lives. A victim who is unlikely to survive even with full treatment is given comfort care, while staff treat salvageable victims. In everyday triage, the sickest patient is usually seen first.
Answer
D · Doing the greatest good for the greatest number
7.Clinical nursing
Answer: C · Hypoxia
Why this is the answer
The 4 Hs are hypoxia, hypovolaemia, hypo- or hyperkalaemia and other metabolic causes, and hypothermia. The 4 Ts are thrombosis, tension pneumothorax, tamponade and toxins.
Answer
C · Hypoxia
8.Clinical nursing
Answer: D · A perforated peptic ulcer
Why this is the answer
Sudden severe pain with a board-like abdomen suggests perforation and peritonitis. The patient needs nil by mouth, IV access, analgesia and urgent surgical review.
Answer
D · A perforated peptic ulcer
9.Lab values & electrolytes
Answer: C · A low serum sodium
Why this is the answer
Carbamazepine (and oxcarbazepine) can cause hyponatremia by increasing the effect of ADH, which can cause confusion, headache and seizures. The drug can also cause serious blood disorders, so the CBC is monitored.Checked against:Syndrome of Inappropriate Antidiuretic Hormone Secretion · StatPearls (NCBI Bookshelf) (2023); Carbamazepine · StatPearls (NCBI Bookshelf) (2023)
Answer
C · A low serum sodium
10.Lab values & electrolytes
Answer: A · IV thiamine
Why this is the answer
People with alcohol use disorder and malnutrition are often deficient in thiamine. Giving glucose first can use up the remaining thiamine and precipitate Wernicke encephalopathy, so thiamine is usually given before or with glucose. Hypoglycemia must still be treated promptly.
Answer
A · IV thiamine
11.Pharmacology
Answer: D · Treatment lasts months, and missed doses cause resistance
Why this is the answer
Standard TB treatment usually lasts six months or more with several drugs. Poor adherence leads to relapse and multidrug-resistant TB, so supervised dosing improves completion.
Answer
D · Treatment lasts months, and missed doses cause resistance
12.Pharmacology
Answer: A · Immature glucuronidation in the liver lets the drug accumulate
Why this is the answer
Neonates have low glucuronyl transferase activity, so chloramphenicol is not conjugated and builds up. High levels cause circulatory collapse with grey skin. It shows how organ immaturity changes pharmacokinetics.
Answer
A · Immature glucuronidation in the liver lets the drug accumulate
13.Med-surg: cardiovascular & respiratory
Answer: A · It can cause bronchospasm by blocking beta-2 receptors
Why this is the answer
Beta-2 receptors in the airways mediate bronchodilation. Blocking them can trigger severe bronchospasm in asthma and also blunts the effect of salbutamol. Cardioselective beta-1 blockers are safer but still used with caution.
Answer
A · It can cause bronchospasm by blocking beta-2 receptors
14.Med-surg: cardiovascular & respiratory
Answer: A · Withhold the next doses and report urgently for liver tests
Why this is the answer
Isoniazid, rifampicin and pyrazinamide can all cause hepatotoxicity. Jaundice, dark urine and nausea suggest drug-induced hepatitis, so the drugs are stopped and liver function is checked urgently. Orange urine from rifampicin does not cause yellow eyes. Alcohol increases the risk.
Answer
A · Withhold the next doses and report urgently for liver tests
15.Med-surg: neuro, endocrine & renal
Answer: B · Acute pancreatitis
Why this is the answer
GLP-1 receptor agonists have been linked to acute pancreatitis. Severe persistent abdominal pain radiating to the back needs urgent assessment, and the drug is stopped if pancreatitis is suspected.
Answer
B · Acute pancreatitis
16.Med-surg: neuro, endocrine & renal
Answer: C · Report it and monitor glucose, as it can worsen outcome
Why this is the answer
Hyperglycaemia is common after stroke and is linked to worse outcomes. It is reported, monitored and treated in line with local protocols, while avoiding hypoglycaemia. The patient may also be tested for undiagnosed diabetes.
Answer
C · Report it and monitor glucose, as it can worsen outcome
17.Med-surg: GI, perioperative & oncology
Answer: A · Ulnar nerve
Why this is the answer
The ulnar nerve runs superficially at the elbow and is a common site of positioning injury. Careful padding and avoiding pressure on the elbow help prevent numbness and weakness of the hand.
Answer
A · Ulnar nerve
18.Med-surg: GI, perioperative & oncology
Answer: C · Ascending cholangitis
Why this is the answer
Fever, jaundice and right upper quadrant pain suggest infection of an obstructed bile duct. It can rapidly cause sepsis and needs blood cultures, IV antibiotics, fluids and urgent biliary drainage, usually by ERCP.
Answer
C · Ascending cholangitis
19.Maternity & obstetric nursing
Answer: A · Low mood and loss of interest lasting more than 2 weeks and affecting daily life
Why this is the answer
Postpartum depression lasts longer than 2 weeks and interferes with caring for herself or the baby. Screening, for example with the Edinburgh Postnatal Depression Scale, and referral are needed.
Answer
A · Low mood and loss of interest lasting more than 2 weeks and affecting daily life
20.Maternity & obstetric nursing
Answer: A · Progestin-only methods are compatible with breastfeeding
Why this is the answer
Progestin-only methods such as implants, injections and pills do not have a clinically important effect on milk supply. Oestrogen-containing methods are usually avoided in the first weeks.
Answer
A · Progestin-only methods are compatible with breastfeeding
21.Pediatric nursing
Answer: A · Jaundice, because the breakdown of the trapped blood adds to bilirubin
Why this is the answer
A cephalohaematoma is a collection of blood under the periosteum. As the red cells break down, bilirubin rises, so these babies have a higher risk of jaundice. The swelling itself usually resolves over weeks without treatment.
Answer
A · Jaundice, because the breakdown of the trapped blood adds to bilirubin
22.Pediatric nursing
Answer: D · "In summer she can drink less so she doesn't need the toilet at school."
Why this is the answer
Dehydration promotes sickling, so children with sickle cell disease need plenty of fluids, especially in hot weather and during exercise. Seeking help for fever, avoiding cold and checking the spleen are correct.
Answer
D · "In summer she can drink less so she doesn't need the toilet at school."
23.Mental health nursing
Answer: C · Codependency
Why this is the answer
Codependency describes a family member whose life becomes centred on the other person's addiction, often with caretaking, covering up and neglect of self. Support groups such as Al-Anon can help.
Answer
C · Codependency
24.Mental health nursing
Answer: B · Assess his suicide risk
Why this is the answer
Stimulant withdrawal can cause profound depression, fatigue, hypersomnia and suicidal thoughts. Suicide risk assessment and close observation are the priorities.
Answer
B · Assess his suicide risk
25.Nursing math & unit conversions
Answer: m = 4.38 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
10 oz/16 = 0.625 lb
9 + 0.625 = 9.625 lb
Pounds to kilograms
m = 9.625/2.2 = 4.375 ≈ 4.38 kg
Answer
m = 4.38 kg
26.Nursing math & unit conversions
Answer: D = 29.7 mg/h
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 = 5 mcg/kg/min × 99 kg × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 5·99·60/1000 = 29.7 mg/h
Answer
D = 29.7 mg/h
27.Dosage calculations
Answer: V = 0.5 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Concentration
1:1000 = 1 g/1000 mL = 1 mg/mL
Volume
V = 0.5/1 = 0.5 mL
Answer
V = 0.5 mL
US labels now state mg/mL (1 mg/mL = 1:1000; 0.1 mg/mL = 1:10 000). Never give 1 mg/mL epinephrine IV push.
28.Dosage calculations
Answer: D = 335.1 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
Body surface area
BSA = √(132·49/3600) = √1.797 = 1.34 m²
Dose
D = 250·1.34 = 335.1 mg
Answer
D = 335.1 mg
29.IV infusion rates
Answer: R = 63 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Time in minutes
4·60 = 240 min
Drip rate
R = 1000·15/240 = 62.5 ≈ 63 gtt/min
Answer
R = 63 gtt/min
At the bedside you round to the nearest whole drop: 63 gtt/min.
30.IV infusion rates
Answer: D = 240 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
400000 mcg/500 mL = 800 mcg/mL
Dose per hour
18·800 = 14400 mcg/h
Dose per minute
D = 14400/60 = 240 mcg/min
Answer
D = 240 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 10.9 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
16·68 = 1 088 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1088/100 = 10.88 ≈ 10.9 mL/h
Answer
R = 10.9 mL/h
32.Pediatric & critical-care dosing
Answer: D = 1.4 mcg/kg/min
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
250 000/250 = 1000 mcg/mL
Micrograms per minute
5·1000 = 5000 mcg/h
5000/60 = 83.33 mcg/min
Per kilogram
D = 83.33/58 = 1.437 ≈ 1.4 mcg/kg/min
Answer
D = 1.4 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 2.84 mL/kg/h
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 urine
350 + 400 + 475 = 1225 mL
Per kilogram per hour
U = 1225/(54·8) = 2.836 ≈ 2.84 mL/kg/h
Answer
U = 2.84 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 4.1 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
120·3 = 360 mL
500 − 360 = 140 mL left
Second part
140/125 = 1.12 h
Total time
t = 3 + 1.12 = 4.12 ≈ 4.1 h
Answer
t = 4.1 h
That is about 4 h 07 min, so the bag runs out at about 11:37.
35.Clinical assessment scores
Answer: MFS = 50
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: none, bed rest or nurse assists → 0
IV therapy or saline lock: no → 0
gait: weak → 10
mental status: knows own limits → 0
Add
Morse total = 25 + 15 + 0 + 0 + 10 + 0 = 50
Answer
MFS = 50
36.Clinical assessment scores
Answer: obesity class II
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 121/1.82² = 36.53
Category
obesity class II
Answer
obesity class II
37.Arterial blood gas interpretation
Answer: partially 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 7.27: acidaemia (below 7.35)
PaCO₂ 18 mmHg: low (35–45)
HCO₃⁻ 8 mmol/L: low (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 47.6 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
0.7·38 + 21 = 47.6 mmHg
Answer
PaCO₂ = 47.6 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: flutter waves per QRS = 4
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.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 per minute
conduction ratio = 300 ÷ 75 = 4:1
Answer
flutter waves per QRS = 4
40.ECG rhythm strip interpretation
Answer: 2:1 AV block (type undetermined)
2:1 AV block: with two P waves for every QRS, no two conducted P waves follow each other, so you cannot see whether the PR would lengthen (type I) or stay constant (type II) before a non-conducted P wave. From one strip it is called a 2:1 AV block; a longer strip or a change in the conduction ratio decides the type. A narrow QRS makes type I more likely and a wide QRS type II, but neither proves it.
Five steps
1. Rate: R–R = 44 small boxes, 1500 ÷ 44 ≈ 34 per minute.
2. Rhythm: regular, every R–R is 1.76 s.
3. P waves: upright and regular (P–P 0.88 s, 68 per minute), two for every QRS.
4. PR interval: constant at 0.16 s in the conducted beats.
5. QRS: 0.06 s, narrow (below 0.12 s).
Why the type stays open
Every second P wave is not conducted, so no two conducted beats follow each other and a lengthening PR could never show.
2:1 AV block (type undetermined)
Answer
2:1 AV block (type undetermined)
A narrow QRS makes type I more likely and a wide QRS type II, but only a longer strip or a change in the conduction ratio decides.
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