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 measure is appropriate for a patient with a fever who feels hot and uncomfortable?
AExtra blankets to make the patient sweat it out
BRestricting fluids so the patient sweats less during the fever
CAn ice bath until the patient shivers
DLight bedclothes, plenty of fluids and a prescribed antipyretic
2.Nursing fundamentalsHard
Why must concentrated potassium chloride never be given as a quick intravenous injection?
AIt can cause a fatal cardiac arrest
BIt makes the vein turn blue for a week
CIt stops the kidneys from working at once
DIt makes the potassium inactive in the blood
3.Infection control & patient safetyMedium
A nurse receives a needlestick injury from a patient known to have HIV. Why is it important to report it immediately?
AReporting is only needed if the wound bleeds or is deep
BReporting can be done at any time within a month without changing the risk
CReporting is only needed for injuries from IV needles
DPost-exposure prophylaxis works best when started within hours
4.Infection control & patient safetyHard
Why can a patient with severe neutropenia have a serious infection but little redness, swelling or pus?
AChemotherapy kills the bacteria before they can multiply
BNeutropenia makes infections stay limited to the skin
CAntibiotics given with chemotherapy hide all signs of infection
DThere are too few neutrophils to produce the usual inflammatory signs
5.Prioritization & delegationMedium
A stable adult with normal vital signs has a cut on the hand that needs sutures and nothing else. Which ESI level fits?
ALevel 2
BLevel 5
CLevel 3
DLevel 4
6.Prioritization & delegationHard
A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?
ASkin condition over the heels
BBreathing strength, such as vital capacity and the ability to cough
CMuscle strength in the feet and ankles at the start of each morning
DThe patient’s mood and coping
7.Clinical nursingMedium
A patient is started on spironolactone while already taking an ACE inhibitor. Which blood result should be watched most closely?
ACalcium, because both drugs lower it
BGlucose, because both drugs cause hyperglycaemia
CSodium, because both drugs raise it sharply
DPotassium, because both drugs can raise it
8.Clinical nursingHard
A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?
ATo rule out septic arthritis, which can rapidly destroy the joint
BTo check for rheumatoid arthritis antibodies in the joint fluid
CTo measure the patient's cholesterol
DTo prevent osteoporosis
9.Lab values & electrolytesMedium
A patient with type 1 diabetes has the flu, is eating little and has a glucose of 290 mg/dL (16.1 mmol/L). Which advice is correct?
AStop all insulin until you are eating normally again
BKeep taking insulin and check blood or urine ketones
CDrink only water and avoid all carbohydrate foods
DWait 3 days before checking the glucose again
10.Lab values & electrolytesHard
A patient with blood pressure that is hard to control has a potassium of 2.9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?
APrimary hyperaldosteronism
BSyndrome of inappropriate ADH
CCentral diabetes insipidus
DPrimary adrenal insufficiency
11.PharmacologyMedium
A patient has severe kidney impairment. A drug is mainly excreted unchanged in the urine. What is the usual adjustment?
AReduce the dose or lengthen the dosing interval
BNo change is needed, because the liver takes over
CIncrease the dose to make up for poor absorption
DGive the drug orally instead of intravenously
12.PharmacologyHard
A patient on long-term lithium passes large amounts of dilute urine and is always thirsty. What is the most likely explanation?
ALithium causes type 1 diabetes by destroying the pancreatic beta cells
BLithium increases ADH release from the pituitary
CThe patient is drinking too much and lithium is unrelated
DLithium blocks the kidney's response to ADH (nephrogenic diabetes insipidus)
13.Med-surg: cardiovascular & respiratoryMedium
Why must intravenous potassium chloride never be given as a rapid push or undiluted?
AIt turns into solid crystals inside the vein and blocks it
BIt immediately lowers the blood glucose to dangerous levels
CA sudden high potassium level can cause cardiac arrest
DIt works only when given by mouth
14.Med-surg: cardiovascular & respiratoryHard
A patient's chest drain is accidentally pulled out. What is the immediate action?
AAsk the patient to cough hard to expand the lung
BPush the drain back into the chest and secure it with tape
CLeave the hole uncovered so trapped air can escape
DSeal the site with a sterile occlusive dressing and get help
15.Med-surg: neuro, endocrine & renalMedium
After a change in the levothyroxine dose, when is the TSH usually rechecked?
AAfter about 6–8 weeks
BAfter about 2 years of treatment
CAfter 24 hours
DAfter 3 days
16.Med-surg: neuro, endocrine & renalHard
Weeks after starting insulin, a patient with newly diagnosed type 1 diabetes needs much less insulin and has frequent mild hypos. What is the most likely explanation?
AThe insulin has gone off and should be replaced
BThe patient actually has type 2 diabetes
CThe diabetes has been cured, so insulin can stop
DA honeymoon phase, but insulin is still needed
17.Med-surg: GI, perioperative & oncologyMedium
Which dressing is generally suitable for a wound with heavy exudate?
AA thin transparent film
BAn alginate or foam
CA hydrogel sheet
DDry gauze changed weekly
18.Med-surg: GI, perioperative & oncologyHard
A patient rescued from a house fire has SpO₂ 99% on air but a headache, confusion and cherry-red lips. What should the nurse do?
ARemove the oxygen, because the oxygen saturation is completely normal
BGive 100% oxygen by non-rebreather and request a carboxyhaemoglobin level
CTreat the headache with paracetamol and observe the patient overnight
DGive oxygen at 2 L/min by nasal cannula and recheck in an hour
19.Maternity & obstetric nursingMedium
Parents ask where their newborn should sleep at night. Which advice reduces the risk of sudden infant death?
AOn a sofa with a parent when the baby is unsettled
BIn the parents' bed, between the two adults
CIn a separate bedroom from the first night
DIn a separate cot or crib in the parents' room
20.Maternity & obstetric nursingHard
Which newborn finding requires immediate follow-up?
AMoulding of the head shape after a vaginal birth at term
BAcrocyanosis at 2 hours
CGrunting, nasal flaring and chest retractions at 1 hour
DSmall white spots (milia) on the nose
21.Pediatric nursingMedium
How should a 3-year-old use a metered-dose inhaler?
ADirectly into the mouth without a spacer, while breathing in as fast as possible
BWith a spacer and mask, holding the breath for 10 seconds after each puff
CWith a spacer and face mask, taking several normal breaths after each puff
DWith a spacer, giving all the prescribed puffs into it at the same time
22.Pediatric nursingHard
Which treatment is not routinely recommended for a typical infant with bronchiolitis?
ABronchodilators or corticosteroids
BHelp with feeding or fluids if intake is poor
CGentle nasal suction if the nose is blocked
DOxygen if the saturation is persistently low
23.Mental health nursingMedium
What must a patient be told for consent to a new psychotropic medicine to be valid?
AOnly the name of the medicine and the time of day it will be given
BThe expected benefits, the main risks and the alternatives, including no treatment
CNothing at all, because psychiatric patients cannot give consent
DOnly the benefits, so that the patient is not frightened by the side effects
24.Mental health nursingHard
A voluntary patient who has no immediate risk of harm wants to leave the ward against medical advice. What is the correct general approach?
AHide the patient's belongings
BExplain the risks, inform the team, document the discussion and respect their right to leave according to the law and policy
CTell the patient that staff will restrain them and bring them back to the ward if they try to leave without the doctor's permission
DLock the door to stop the patient leaving
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.27191 mL. The rule in this exercise is that volumes below 1 mL are rounded to the nearest hundredth of a mL. What value x do you record?
0.27191 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 4 mg/h. Express this dose rate D in mcg/min. Round to one decimal place.
4 mg/h1 mg = 1000 mcg1 h = 60 min
D = mcg/min
27.Dosage calculationsMedium
A child weighing 16 kg is prescribed 10 mg/kg of a drug. The stock solution contains 20 mg/mL. Draw up the dose: what volume V do you give?
16 kg10 mg/kg20 mg/mL
V = mL
28.Dosage calculationsHard
A child weighing 24 kg is prescribed 20 mg/kg per dose of an oral suspension that contains 125 mg in 5 mL. What volume V do you give?
24 kg20 mg/kg125 mg/5 mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 3 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1500 mL3 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
1000 mL was ordered over 8 hours. After 3 hours you find that 660 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1000 mL / 8 hafter 3 h: 660 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 12 units/kg/h for a patient who weighs 59 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL12 units/kg/h59 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 18 mL/h. The patient weighs 50 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL18 mL/h50 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. Count ice chips as half their volume.
juice: 100 mLwater: 350 mLice chips: 120 mLIV infusion: 125 mL/h × 8 hIV antibiotic: 2 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL infusion starts at 06:30 at 80 mL/h. After 4 hours the rate is changed to 200 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL80 mL/h · 4 h200 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient after a head injury does not open the eyes at all, makes only incomprehensible sounds such as moaning and shows as the best motor response: abnormal flexion of the arms (decorticate posture). Work out the GCS and classify the head injury by it. Click your answer.
1mild
2moderate
3severe
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 53 kg and is 183 cm tall. Calculate the BMI and click the WHO weight category.
53 kg183 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 150 mmol/L, glucose 17.1 mmol/L and urea 9.2 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 150 mmol/Lglucose 17.1 mmol/Lurea 9.2 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 139, Cl⁻ 114, HCO₃⁻ 17 mmol/L and albumin 38 g/L. Find the albumin-corrected anion gap AGc = AG + 0.25·(40 − albumin).
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
1normal sinus rhythm
2sinus arrhythmia
3junctional rhythm
4sinus tachycardia
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. Measure the P–P interval and find the atrial rate in beats per minute (1500 method, whole number).
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
atrial rate = bpm
3Solutions
1.Nursing fundamentals
Answer: D · Light bedclothes, plenty of fluids and a prescribed antipyretic
Why this is the answer
Light clothing, fluids and antipyretics such as paracetamol (acetaminophen) increase comfort and replace fluid lost through sweating. Very cold sponging causes shivering, which produces heat.
Answer
D · Light bedclothes, plenty of fluids and a prescribed antipyretic
2.Nursing fundamentals
Answer: A · It can cause a fatal cardiac arrest
Why this is the answer
A sudden rise in blood potassium can stop the heart. IV potassium is given diluted, by a controlled infusion and following strict policy, which is why concentrated forms are tightly controlled.
Answer
A · It can cause a fatal cardiac arrest
3.Infection control & patient safety
Answer: D · Post-exposure prophylaxis works best when started within hours
Why this is the answer
After washing the wound with soap and water, the nurse reports at once so the exposure can be assessed. HIV post-exposure prophylaxis should start as soon as possible, ideally within hours and no later than 72 hours.
Answer
D · Post-exposure prophylaxis works best when started within hours
4.Infection control & patient safety
Answer: D · There are too few neutrophils to produce the usual inflammatory signs
Why this is the answer
Classic signs of infection come from the inflammatory response, which depends on white blood cells. With very few neutrophils, fever may be the only early sign, so it must be taken seriously.
Answer
D · There are too few neutrophils to produce the usual inflammatory signs
5.Prioritization & delegation
Answer: D · Level 4
Why this is the answer
For a stable patient, ESI levels 3 to 5 depend on the expected resources: two or more is level 3, one is level 4 and none is level 5. Simple suturing counts as one resource, so this is level 4.
Answer
D · Level 4
6.Prioritization & delegation
Answer: B · Breathing strength, such as vital capacity and the ability to cough
Why this is the answer
Guillain-Barré syndrome causes ascending weakness that can involve the respiratory muscles. Falling vital capacity or a weak cough can mean the patient needs ventilation, so breathing is monitored closely.
Answer
B · Breathing strength, such as vital capacity and the ability to cough
7.Clinical nursing
Answer: D · Potassium, because both drugs can raise it
Why this is the answer
Spironolactone and ACE inhibitors both reduce potassium excretion, so the combination can cause dangerous hyperkalaemia. Potassium and renal function should be checked regularly.
Answer
D · Potassium, because both drugs can raise it
8.Clinical nursing
Answer: A · To rule out septic arthritis, which can rapidly destroy the joint
Why this is the answer
Septic arthritis can destroy cartilage within days. Aspiration allows microscopy and culture, and helps distinguish infection from crystal arthritis such as gout.
Answer
A · To rule out septic arthritis, which can rapidly destroy the joint
9.Lab values & electrolytes
Answer: B · Keep taking insulin and check blood or urine ketones
Why this is the answer
During illness, stress hormones raise glucose, so insulin is continued even when eating less. Glucose and ketones are checked often, fluids are taken, and the provider is contacted if ketones are moderate or high or vomiting prevents fluids.Checked against:Diabetes - when you are sick · MedlinePlus (NIH) (2026)
Answer
B · Keep taking insulin and check blood or urine ketones
10.Lab values & electrolytes
Answer: A · Primary hyperaldosteronism
Why this is the answer
Excess aldosterone causes sodium and water retention (hypertension), potassium loss (hypokalemia) and hydrogen ion loss (metabolic alkalosis). Adrenal insufficiency causes the opposite pattern, with low sodium and high potassium.Checked against:Primary and secondary hyperaldosteronism · MedlinePlus (NIH) (2025); Alkalosis · StatPearls (NCBI Bookshelf) (2024)
Answer
A · Primary hyperaldosteronism
11.Pharmacology
Answer: A · Reduce the dose or lengthen the dosing interval
Why this is the answer
When renal clearance falls, drugs excreted by the kidney accumulate. The dose is lowered or given less often, guided by kidney function and, where possible, drug levels.
Answer
A · Reduce the dose or lengthen the dosing interval
12.Pharmacology
Answer: D · Lithium blocks the kidney's response to ADH (nephrogenic diabetes insipidus)
Why this is the answer
Lithium interferes with ADH action in the collecting duct, causing polyuria and polydipsia. Dehydration from this can raise lithium levels further, so fluid balance matters.
Answer
D · Lithium blocks the kidney's response to ADH (nephrogenic diabetes insipidus)
13.Med-surg: cardiovascular & respiratory
Answer: C · A sudden high potassium level can cause cardiac arrest
Why this is the answer
Rapid or concentrated IV potassium can cause cardiac arrest. It is given diluted, by infusion, at controlled rates (often with a pump and ECG monitoring for higher rates). Concentrated ampoules are tightly controlled in hospitals because of fatal errors.
Answer
C · A sudden high potassium level can cause cardiac arrest
14.Med-surg: cardiovascular & respiratory
Answer: D · Seal the site with a sterile occlusive dressing and get help
Why this is the answer
The site is covered immediately with a sterile occlusive dressing to prevent air entering the chest. The patient is assessed for a recurring or tension pneumothorax (increasing breathlessness, falling saturation, tachycardia, tracheal shift) and the medical team informed. A drain is never reinserted.
Answer
D · Seal the site with a sterile occlusive dressing and get help
15.Med-surg: neuro, endocrine & renal
Answer: A · After about 6–8 weeks
Why this is the answer
Levothyroxine has a half-life of about a week, so it takes several weeks to reach a new steady state. TSH is usually rechecked about 6–8 weeks after a dose change.
Answer
A · After about 6–8 weeks
16.Med-surg: neuro, endocrine & renal
Answer: D · A honeymoon phase, but insulin is still needed
Why this is the answer
After diagnosis and correction of high glucose, remaining beta cells may work better for a while, so insulin needs fall. This honeymoon phase is temporary. The doses are reduced, but insulin is not stopped.
Answer
D · A honeymoon phase, but insulin is still needed
17.Med-surg: GI, perioperative & oncology
Answer: B · An alginate or foam
Why this is the answer
Alginates and foams absorb large amounts of exudate. Hydrogels add moisture to dry wounds, films suit superficial wounds with little exudate and dry gauze sticks to the wound bed. The surrounding skin is protected from maceration.
Answer
B · An alginate or foam
18.Med-surg: GI, perioperative & oncology
Answer: B · Give 100% oxygen by non-rebreather and request a carboxyhaemoglobin level
Why this is the answer
Carbon monoxide binds haemoglobin more strongly than oxygen. Standard pulse oximetry reads carboxyhaemoglobin as oxyhaemoglobin, so SpO₂ may look normal. High-concentration oxygen speeds CO elimination. A co-oximetry blood gas measures carboxyhaemoglobin.
Answer
B · Give 100% oxygen by non-rebreather and request a carboxyhaemoglobin level
19.Maternity & obstetric nursing
Answer: D · In a separate cot or crib in the parents' room
Why this is the answer
Both US (AAP) and UK (NHS) guidance advise room-sharing without bed-sharing: the baby sleeps on the back in a cot or crib in the parents' room for at least the first 6 months. Sleeping with a baby on a sofa or armchair is especially dangerous.
Answer
D · In a separate cot or crib in the parents' room
20.Maternity & obstetric nursing
Answer: C · Grunting, nasal flaring and chest retractions at 1 hour
Why this is the answer
Grunting, flaring and retractions are signs of respiratory distress and need urgent assessment. Acrocyanosis, milia and moulding are common normal findings.
Answer
C · Grunting, nasal flaring and chest retractions at 1 hour
21.Pediatric nursing
Answer: C · With a spacer and face mask, taking several normal breaths after each puff
Why this is the answer
Young children need a spacer with a well-fitting face mask. One puff is given at a time, and the child breathes normally for several breaths (often 5–10) to inhale the medicine. Several puffs at once reduce the dose delivered.
Answer
C · With a spacer and face mask, taking several normal breaths after each puff
22.Pediatric nursing
Answer: A · Bronchodilators or corticosteroids
Why this is the answer
Guidelines advise supportive care for bronchiolitis: oxygen when needed, fluids or feeding support and suction of blocked noses. Bronchodilators, steroids and antibiotics have not been shown to help typical cases and are not routinely used.
Answer
A · Bronchodilators or corticosteroids
23.Mental health nursing
Answer: B · 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
B · The expected benefits, the main risks and the alternatives, including no treatment
24.Mental health nursing
Answer: B · Explain the risks, inform the team, document the discussion and respect their right to leave according to the law and policy
Why this is the answer
Voluntary patients can usually leave, although they may be asked to wait while their risk is assessed. Detaining someone needs legal authority. The nurse informs the team, assesses risk and documents.
Answer
B · Explain the risks, inform the team, document the discussion and respect their right to leave according to the law and policy
25.Nursing math & unit conversions
Answer: x = 0.27 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the hundredths place
0.27191 → 7
Only the next digit decides
0.27191 → 1
1 is 4 or less, so 7 stays.
The digits after it (91) are ignored: round once, never step by step.
Round
x = 0.27 mL
Answer
x = 0.27 mL
26.Nursing math & unit conversions
Answer: D = 66.7 mcg/min
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 4 mg/h × (1000 mcg/1 mg) × (1 h/60 min)
Calculate
D = 4000/60 = 66.67 ≈ 66.7 mcg/min
Answer
D = 66.7 mcg/min
27.Dosage calculations
Answer: V = 8 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 = 10·16 = 160 mg
Volume
V = 160/20 = 8 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 8 mL
28.Dosage calculations
Answer: V = 19.2 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose from weight
20·24 = 480 mg
Volume
V = (480/125)·5 = 19.2 mL
Answer
V = 19.2 mL
29.IV infusion rates
Answer: R = 83 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
3·60 = 180 min
Drip rate
R = 1500·10/180 = 83.33 ≈ 83 gtt/min
Answer
R = 83 gtt/min
At the bedside you round to the nearest whole drop: 83 gtt/min.
30.IV infusion rates
Answer: Δ = 5.6 %
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
1000/8 = 125 mL/h
New rate
R = 660/5 = 132 mL/h
Percentage change
Δ = (132 − 125)/125·100% = 5.6%
Answer
Δ = 5.6%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: R = 17.7 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.
Units per hour
12·59 = 708 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 708/40 = 17.7 mL/h
Answer
R = 17.7 mL/h
32.Pediatric & critical-care dosing
Answer: D = 6 mcg/kg/min
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
250 000/250 = 1000 mcg/mL
Micrograms per minute
18·1000 = 18000 mcg/h
18000/60 = 300 mcg/min
Per kilogram
D = 300/50 = 6 mcg/kg/min
Answer
D = 6 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 1710 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 + 350 = 450 mL
ice chips: 120/2 = 60 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 2·100 = 200 mL
I = 1710 mL
Answer
I = 1710 mL
34.IV fluids & fluid balance
Answer: t = 7.4 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
80·4 = 320 mL
1000 − 320 = 680 mL left
Second part
680/200 = 3.4 h
Total time
t = 4 + 3.4 = 7.4 h
Answer
t = 7.4 h
That is about 7 h 24 min, so the bag runs out at about 13:54.
35.Clinical assessment scores
Answer: severe
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Score each area
E: does not open the eyes at all → 1
V: makes only incomprehensible sounds such as moaning → 2
M: abnormal flexion of the arms (decorticate posture) → 3
Add
GCS = 1 + 2 + 3 = 6
Severity
GCS 6 → severe
Answer
severe
36.Clinical assessment scores
Answer: underweight
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 = 53/1.83² = 15.83
Category
underweight
Answer
underweight
37.Arterial blood gas interpretation
Answer: Osm = 326 mOsm/kg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Calculated osmolality
Osm = 2·150 + 17.1 + 9.2 = 326.3 ≈ 326 mOsm/kg
Answer
Osm = 326 mOsm/kg
38.Arterial blood gas interpretation
Answer: AGc = 8.5 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.
Anion gap
AG = 139 − (114 + 17) = 8
Correction for albumin
8 + 0.25·(40 − 38) = 8.5 mmol/L
Answer
AGc = 8.5 mmol/L
Still within about 8–12 after correction.
39.ECG rhythm strip interpretation
Answer: normal sinus rhythm
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: R–R = 22 small boxes, 1500 ÷ 22 ≈ 68 per minute.
2. Rhythm: regular, every R–R is 0.88 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
normal sinus rhythm
Answer
normal sinus rhythm
40.ECG rhythm strip interpretation
Answer: atrial rate = 71 bpm
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.
Atrial rate
P–P = 21 small boxes = 0.84 s → 1500 ÷ 21 = 71.43 ≈ 71 per minute
Ventricular rate
R–R = 42 small boxes = 1.68 s → 1500 ÷ 42 = 35.71 ≈ 36 per minute
Answer
atrial rate = 71 bpm
Answer
atrial rate = 71 bpm
2:1 AV block: every second P wave is not conducted, so the atrial rate is twice the ventricular rate.
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