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
At what angle is an intramuscular injection given?
A15 degrees
B90 degrees
C45 degrees
D30 degrees
2.Nursing fundamentalsHard
In the SBAR communication tool, what does the "A" stand for?
AAssessment
BAllergies
CAction
DAdmission
3.Infection control & patient safetyMedium
A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?
AVisit but avoid touching the patient’s bed
BPostpone the visit until the visitor is well
CVisit only if the cold started more than a day ago
DVisit as usual after washing the hands
4.Infection control & patient safetyHard
Which patient should the nurse assess first?
AA patient with tuberculosis who is asking to have visitors
BA patient with an MRSA wound due for a routine dressing change
CA patient who wants more alcohol hand rub in the room
DA patient on chemotherapy with a new temperature of 38.4 °C (101.1 °F)
5.Prioritization & delegationMedium
Which SBAR recommendation is the clearest?
A“I just wanted to let you know about him.”
B“I will keep watching him and call again tomorrow.”
C“He seems a bit off tonight, so maybe you could come up and do something about it.”
D“I would like you to see him within 15 minutes and consider a fluid bolus.”
6.Prioritization & delegationHard
Which patient needs airborne precautions rather than droplet precautions?
AA child with pertussis (whooping cough)
BA teenager with mumps
CA child with chickenpox (varicella)
DAn adult with influenza
7.Clinical nursingMedium
Why are alternate sutures sometimes removed first when taking out stitches?
ATo make the procedure faster
BBecause the remaining sutures dissolve on their own within a day
CTo reduce the cost of dressings
DTo check the wound stays closed before removing the rest
8.Clinical nursingHard
A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?
AIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids
BPost-renal acute kidney injury from obstruction, treated with a catheter
CPre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
DChronic kidney disease, treated with long-term dialysis three times a week
9.Lab values & electrolytesMedium
Which group of findings fits hypercalcemia?
AThirst with very dilute urine as the only signs
BPeaked T waves and muscle weakness only
CConstipation, fatigue, confusion and kidney stones
DTetany, muscle cramps and a positive Chvostek’s sign
10.Lab values & electrolytesHard
A patient has fatigue, weight loss, darkening of the skin and low blood pressure. Results: sodium 130 mEq/L, potassium 5.6 mEq/L. Which test pattern would confirm primary adrenal insufficiency (Addison disease)?
ALow cortisol with a low ACTH
BHigh cortisol with a low ACTH
CLow cortisol with a high ACTH
DHigh cortisol with a high ACTH
11.PharmacologyMedium
Which statement about allopurinol is correct?
AIt works within an hour to relieve joint pain
BIt lowers uric acid over time and does not relieve the pain of an acute attack
CIt is taken only during an acute attack and stopped as soon as the pain settles
DIt increases uric acid production to flush out crystals
12.PharmacologyHard
A patient recently started on haloperidol develops high fever, "lead-pipe" muscle rigidity, confusion and a very high creatine kinase. What is the most likely diagnosis?
ASerotonin syndrome
BMalignant hyperthermia from anaesthesia
CNeuroleptic malignant syndrome
DAcute dystonia
13.Med-surg: cardiovascular & respiratoryMedium
Rheumatic heart disease most often follows which infection?
AA group A streptococcal throat infection
BA viral infection of the upper airway
CA fungal infection of the lungs
DStaphylococcal infection of the skin
14.Med-surg: cardiovascular & respiratoryHard
A breathless patient on a non-rebreather mask at 15 L/min has a reservoir bag that collapses completely with each breath. What should the nurse do?
ACheck the oxygen supply and flow so the bag stays inflated
BReduce the flow to 2 L/min to stop the bag collapsing
CRemove the bag, as the mask works without it
DLeave it, because a collapsing bag shows a good seal
15.Med-surg: neuro, endocrine & renalMedium
An 85-year-old care home resident becomes newly confused and is falling more often. A UTI is one possibility. Why?
AUrinary infections always cause a high fever in older adults
BA UTI cannot occur in people over 80
CConfusion is the only symptom of a UTI at any age
DOlder adults often show infection as confusion
16.Med-surg: neuro, endocrine & renalHard
A seizure has lasted 12 minutes. Two doses of benzodiazepine have been given, and the seizure continues. Airway and oxygen are managed. What is the next step in common protocols?
AGiving oral antiseizure tablets once the patient can swallow
BWaiting another 30 minutes to see whether the seizure stops
CA third and fourth dose of benzodiazepine every two minutes
DA second-line IV drug such as levetiracetam or phenytoin
17.Med-surg: GI, perioperative & oncologyMedium
Which is a usual benefit of laparoscopic over open abdominal surgery?
ANo need for a general anaesthetic ever
BNo risk of any complications at all
CLarger wounds that heal faster
DLess pain and a shorter hospital stay
18.Med-surg: GI, perioperative & oncologyHard
On day 3 after admission, a patient with alcohol dependence becomes confused, with hallucinations, sweating, tremor, fever and tachycardia. What is the most likely cause?
ANormal anxiety about being in hospital
BHepatitis A caught on the ward
CAn allergic reaction to hospital food
DDelirium tremens from alcohol withdrawal
19.Maternity & obstetric nursingMedium
Methylergonovine (methylergometrine) for postpartum bleeding should not be given to a woman with:
AType 1 diabetes
BAsthma
CHigh blood pressure
DAnaemia
20.Maternity & obstetric nursingHard
A woman attempting a vaginal birth after a previous caesarean suddenly has severe abdominal pain, the fetal heart rate drops sharply and the presenting part can no longer be felt. What is most likely?
APlacenta praevia
BUterine rupture
CNormal progress into the second stage
DEarly decelerations from head compression
21.Pediatric nursingMedium
A child with a myelomeningocele has a neurogenic bladder. Which management is usual?
ARestricting fluids to reduce urine volume
BWaiting for bladder control to develop naturally
CA permanent catheter left in place for life
DClean intermittent catheterisation
22.Pediatric nursingHard
A 12-year-old with asthma has been prescribed a preventer inhaler (inhaled corticosteroid) to take every day. Which statement shows a need for further teaching?
A"I stop taking my preventer inhaler whenever I've had a few good days."
B"I carry my reliever inhaler with me everywhere I go."
C"I rinse my mouth after using my preventer inhaler."
D"I use my spacer with my inhaler, even at school."
23.Mental health nursingMedium
In the mental status examination, which finding is recorded under thought content?
APressured speech
BFlight of ideas
CLoose associations
DObsessions and delusions
24.Mental health nursingHard
During a panic attack, a patient breathes very fast and complains of light-headedness and tingling in her fingers and around her mouth. What should the nurse do?
ALeave her alone so that she can calm down without anyone watching
BStay with her and coach her to breathe slowly and steadily
CAsk her to breathe into a paper bag for at least 10 minutes
DGive her oxygen at a high flow rate through a mask
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 05:45 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
05:45
15:45 AM
24:45 AM
37:45 AM
45:45 PM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A serum creatinine result is 2.7 mg/dL. Using 1 mg/dL = 88.4 µmol/L for creatinine, find c in µmol/L to the nearest whole number.
2.7 mg/dL1 mg/dL = 88.4 µmol/L
c = µmol/L
27.Dosage calculationsMedium
A patient weighs 90 kg. The prescribed dose is 2 mg/kg per day, given in 3 equal doses. How many milligrams D are given per dose?
90 kg2 mg/kg/day3× per day
D = mg
28.Dosage calculationsHard
A child weighing 14 kg is prescribed 10 mg/kg per dose of an oral suspension that contains 125 mg in 5 mL. What volume V do you give?
14 kg10 mg/kg125 mg/5 mL
V = mL
29.IV infusion ratesMedium
500 mL was ordered over 6 hours. After 4 hours you find that 190 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
500 mL / 6 hafter 4 h: 190 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 4 g of a drug in 500 mL. The order is 2 mg per minute. At what rate R do you set the pump, in mL/h?
4 g/500 mL2 mg/min
R = mL/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 500 mL. The order is 20 units/kg/h for a patient who weighs 91 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL20 units/kg/h91 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dopamine infusion of 400 mg in 250 mL runs at 11 mL/h. The patient weighs 85 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
400 mg/250 mL11 mL/h85 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 12-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 1000 mL bag runs by pump at 125 mL/h. At 16:30, 50 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL50 mL infused125 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: no impairment; moisture: very moist; activity: walks frequently; mobility: slightly limited; nutrition: probably inadequate; friction and shear: no apparent problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 7/min, SpO₂ 97% on room air, blood pressure 124/74 mmHg, pulse 64/min, alert, temperature 36.8 °C. Which clinical risk group does the patient fall into? Click it.
RR 7SpO₂ 97%airSBP 124HR 64AT 36.8 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.11, PaCO₂ 78 mmHg (10.4 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory acidosis. How far is it compensated? Click your answer.
pH 7.11PaCO₂ 78 mmHg (10.4 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 136, Cl⁻ 115, HCO₃⁻ 10 mmol/L and albumin 27 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
1sinus bradycardia
2junctional rhythm
3sinus tachycardia
4first-degree AV block
40.ECG rhythm strip interpretationHard
A patient without a palpable pulse has this organised rhythm on the monitor (pulseless electrical activity). Which treatment do adult resuscitation guidelines name for 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
1synchronised cardioversion
2CPR (non-shockable rhythm)
3immediate defibrillation
4transcutaneous pacing
3Solutions
1.Nursing fundamentals
Answer: B · 90 degrees
Why this is the answer
Intramuscular injections are given at 90 degrees so the needle passes through the skin and fat into the muscle. Intradermal injections use about 10–15 degrees.
Answer
B · 90 degrees
2.Nursing fundamentals
Answer: A · Assessment
Why this is the answer
SBAR: Situation, Background, Assessment (your clinical judgement of the problem) and Recommendation (what you need).
Answer
A · Assessment
3.Infection control & patient safety
Answer: B · Postpone the visit until the visitor is well
Why this is the answer
Patients with severe neutropenia cannot fight infections well. People with respiratory or other infections should not visit until they are well; other visitors perform hand hygiene.
Answer
B · Postpone the visit until the visitor is well
4.Infection control & patient safety
Answer: D · A patient on chemotherapy with a new temperature of 38.4 °C (101.1 °F)
Why this is the answer
Fever in a patient who may be neutropenic can be the first sign of sepsis and needs urgent assessment. The other needs are real but stable and can wait a short time.
Answer
D · A patient on chemotherapy with a new temperature of 38.4 °C (101.1 °F)
5.Prioritization & delegation
Answer: D · “I would like you to see him within 15 minutes and consider a fluid bolus.”
Why this is the answer
A good recommendation is specific about the request and the time frame. Vague statements leave the provider unsure how urgent the problem is.
Answer
D · “I would like you to see him within 15 minutes and consider a fluid bolus.”
6.Prioritization & delegation
Answer: C · A child with chickenpox (varicella)
Why this is the answer
Varicella spreads by the airborne route (and contact), so it needs an airborne infection isolation room. Influenza, pertussis and mumps are spread mainly by droplets.
Answer
C · A child with chickenpox (varicella)
7.Clinical nursing
Answer: D · To check the wound stays closed before removing the rest
Why this is the answer
Removing alternate sutures allows the nurse to see whether the wound edges stay together. If they begin to separate, the remaining sutures can be left and the team informed.
Answer
D · To check the wound stays closed before removing the rest
8.Clinical nursing
Answer: C · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
Why this is the answer
Fluid loss reduces kidney perfusion, causing pre-renal AKI. Prompt fluid replacement can restore function before the kidney tissue itself is damaged.
Answer
C · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
9.Lab values & electrolytes
Answer: C · Constipation, fatigue, confusion and kidney stones
Why this is the answer
High calcium reduces nerve and muscle excitability, causing fatigue, constipation, confusion, bone pain and kidney stones. Tetany and Chvostek’s sign are signs of low calcium.Checked against:Calcium Blood Test · MedlinePlus (NIH) (2024)
Answer
C · Constipation, fatigue, confusion and kidney stones
10.Lab values & electrolytes
Answer: C · Low cortisol with a high ACTH
Why this is the answer
In primary adrenal insufficiency the adrenal glands fail, so cortisol is low and the pituitary responds with high ACTH, which also darkens the skin. Low cortisol with low ACTH suggests a pituitary cause. An ACTH stimulation test confirms the diagnosis.Checked against:Adrenocorticotropic Hormone (ACTH) · MedlinePlus (NIH) (2023); Cortisol Test · MedlinePlus (NIH) (2024)
Answer
C · Low cortisol with a high ACTH
11.Pharmacology
Answer: B · It lowers uric acid over time and does not relieve the pain of an acute attack
Why this is the answer
Allopurinol reduces urate production and is taken daily to prevent attacks. Acute attacks are treated with NSAIDs, colchicine or corticosteroids, and a new rash on allopurinol must be reported.
Answer
B · It lowers uric acid over time and does not relieve the pain of an acute attack
12.Pharmacology
Answer: C · Neuroleptic malignant syndrome
Why this is the answer
Neuroleptic malignant syndrome follows dopamine antagonists and develops over days, with lead-pipe rigidity, fever and raised CK. Serotonin syndrome develops faster and features clonus and hyperreflexia.
Answer
C · Neuroleptic malignant syndrome
13.Med-surg: cardiovascular & respiratory
Answer: A · A group A streptococcal throat infection
Why this is the answer
Rheumatic fever is an autoimmune reaction weeks after group A streptococcal pharyngitis. It can permanently damage heart valves, most often the mitral valve. Prompt antibiotic treatment of strep throat prevents it.
Answer
A · A group A streptococcal throat infection
14.Med-surg: cardiovascular & respiratory
Answer: A · Check the oxygen supply and flow so the bag stays inflated
Why this is the answer
The reservoir bag should be filled before the mask is applied and stay at least partly inflated during inspiration. A fully collapsing bag means the patient is not getting enough oxygen and may be breathing in room air. Check the supply and flow, and escalate if the patient remains hypoxic.
Answer
A · Check the oxygen supply and flow so the bag stays inflated
15.Med-surg: neuro, endocrine & renal
Answer: D · Older adults often show infection as confusion
Why this is the answer
In older adults, infections such as UTI may present with delirium, falls or reduced mobility rather than dysuria or fever. Other causes of delirium must also be considered, and urine tests alone can mislead.
Answer
D · Older adults often show infection as confusion
16.Med-surg: neuro, endocrine & renal
Answer: D · A second-line IV drug such as levetiracetam or phenytoin
Why this is the answer
Status epilepticus that continues after two doses of benzodiazepine (established status) is treated with a second-line IV drug. If it still continues (refractory status), anaesthesia and intubation in critical care are needed. Glucose, airway and monitoring continue throughout. Repeated benzodiazepines increase respiratory depression without much extra benefit.
Answer
D · A second-line IV drug such as levetiracetam or phenytoin
17.Med-surg: GI, perioperative & oncology
Answer: D · Less pain and a shorter hospital stay
Why this is the answer
Smaller incisions usually mean less pain, faster mobilisation, fewer wound complications and shorter stays. There are still risks, including injury to organs and shoulder-tip pain from the gas.
Answer
D · Less pain and a shorter hospital stay
18.Med-surg: GI, perioperative & oncology
Answer: D · Delirium tremens from alcohol withdrawal
Why this is the answer
Delirium tremens usually develops 2–3 days after stopping alcohol and is a medical emergency. It is treated with benzodiazepines, fluids, thiamine and close monitoring, ideally prevented by a withdrawal protocol.
Answer
D · Delirium tremens from alcohol withdrawal
19.Maternity & obstetric nursing
Answer: C · High blood pressure
Why this is the answer
Ergot alkaloids cause vasoconstriction and can raise blood pressure dangerously, so they are avoided in hypertension and pre-eclampsia. Carboprost is the drug to avoid in asthma.
Answer
C · High blood pressure
20.Maternity & obstetric nursing
Answer: B · Uterine rupture
Why this is the answer
Sudden pain, fetal bradycardia and loss of station are classic signs of uterine rupture, a rare but life-threatening emergency that requires immediate surgery.
Answer
B · Uterine rupture
21.Pediatric nursing
Answer: D · Clean intermittent catheterisation
Why this is the answer
Damage to the spinal nerves causes a bladder that does not empty fully, risking infection and kidney damage. Clean intermittent catheterisation several times a day, taught to parents and later to the child, is the usual approach.
Answer
D · Clean intermittent catheterisation
22.Pediatric nursing
Answer: A · "I stop taking my preventer inhaler whenever I've had a few good days."
Why this is the answer
Preventer (inhaled corticosteroid) inhalers reduce airway inflammation and must be taken daily as prescribed, even when the child feels well. Carrying a reliever, rinsing the mouth and using a spacer are correct.
Answer
A · "I stop taking my preventer inhaler whenever I've had a few good days."
23.Mental health nursing
Answer: D · Obsessions and delusions
Why this is the answer
Thought content covers delusions, obsessions, phobias and suicidal or homicidal thoughts. Thought process (form) covers loose associations, tangentiality and flight of ideas.
Answer
D · Obsessions and delusions
24.Mental health nursing
Answer: B · Stay with her and coach her to breathe slowly and steadily
Why this is the answer
Hyperventilation causes respiratory alkalosis, which leads to tingling and dizziness. Calm coaching of slow breathing restores carbon dioxide levels. Breathing into a paper bag is not recommended, because it can cause hypoxia and mask a medical cause.
Answer
B · Stay with her and coach her to breathe slowly and steadily
25.Nursing math & unit conversions
Answer: 5:45 AM
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
05 → 5 AM
Answer
5:45 AM
Answer
5:45 AM
26.Nursing math & unit conversions
Answer: c = 239 µmol/L
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.
Convert
c = 2.7·88.4 = 238.7 ≈ 239 µmol/L
Answer
c = 239 µmol/L
27.Dosage calculations
Answer: D = 60 mg
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Total per day
2·90 = 180 mg
Per dose
D = 180/3 = 60 mg
Answer
D = 60 mg
28.Dosage calculations
Answer: V = 5.6 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
10·14 = 140 mg
Volume
V = (140/125)·5 = 5.6 mL
Answer
V = 5.6 mL
29.IV infusion rates
Answer: R = 95 mL/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
500/6 = 83.33 mL/h
New rate
R = 190/2 = 95 mL/h
Answer
R = 95 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: R = 15 mL/h
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
4000 mg/500 mL = 8 mg/mL
Dose per hour
2·60 = 120 mg/h
Pump rate
R = 120/8 = 15 mL/h
Answer
R = 15 mL/h
31.Pediatric & critical-care dosing
Answer: R = 36.4 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
20·91 = 1 820 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 1820/50 = 36.4 mL/h
Answer
R = 36.4 mL/h
32.Pediatric & critical-care dosing
Answer: D = 3.5 mcg/kg/min
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
400 000/250 = 1600 mcg/mL
Micrograms per minute
11·1600 = 17600 mcg/h
17600/60 = 293.3 mcg/min
Per kilogram
D = 293.3/85 = 3.451 ≈ 3.5 mcg/kg/min
Answer
D = 3.5 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 1270 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Add the intake
oral: 120 + 150 + 200 = 470 mL
ice chips: 200/2 = 100 mL
IV infusion: 50·12 = 600 mL
IV antibiotic: 1·100 = 100 mL
I = 1270 mL
Answer
I = 1270 mL
34.IV fluids & fluid balance
Answer: t = 7.6 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
1000 − 50 = 950 mL
Time
t = 950/125 = 7.6 h
Answer
t = 7.6 h
That is about 7 h 36 min, so the bag runs out at about 00:06.
35.Clinical assessment scores
Answer: B = 18
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: no impairment → 4
moisture: very moist → 2
activity: walks frequently → 4
mobility: slightly limited → 3
nutrition: probably inadequate → 2
friction and shear: no apparent problem → 3
Add
Braden total = 4 + 2 + 4 + 3 + 2 + 3 = 18
Answer
B = 18
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 7/min → 3
SpO₂ 97% → 0
on air → 0
SBP 124 mmHg → 0
HR 64/min → 0
alert (A) → 0
T 36.8 °C → 0
Total and red scores
NEWS2 = 3 + 0 + 0 + 0 + 0 + 0 + 0 = 3
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: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.11: acidaemia (below 7.35)
PaCO₂ 78 mmHg: high (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: AGc = 14.25 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 = 136 − (115 + 10) = 11
Correction for albumin
11 + 0.25·(40 − 27) = 14.25 mmol/L
Answer
AGc = 14.25 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: first-degree AV block
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 = 17 small boxes, 1500 ÷ 17 ≈ 88 per minute.
2. Rhythm: regular, every R–R is 0.68 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.24 s, constant, longer than 0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
first-degree AV block
Answer
first-degree AV block
40.ECG rhythm strip interpretation
Answer: CPR (non-shockable rhythm)
Pulseless electrical activity (PEA): PEA cannot be seen on a strip. The monitor shows organised electrical activity (a rhythm other than VF, VT or asystole) but the patient has no palpable pulse, so it is recognised by checking the patient. In adult resuscitation guidelines PEA and asystole are the non-shockable cardiac arrest rhythms: high-quality CPR, epinephrine as soon as possible and a search for reversible causes (the Hs and Ts, such as hypovolaemia, hypoxia, tension pneumothorax and cardiac tamponade). VF and pulseless VT are the shockable rhythms.
What the strip shows
1. Rate: R–R = 13 small boxes, 1500 ÷ 13 ≈ 115 per minute.
2. Rhythm: regular, every R–R is 0.52 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.12 s, constant, within 0.12–0.20 s.
5. QRS: 0.10 s, narrow (below 0.12 s).
sinus tachycardia
What the patient shows
no pulse despite organised electrical activity: pulseless electrical activity (PEA), a non-shockable cardiac arrest rhythm
Answer
CPR (non-shockable rhythm)
Answer
CPR (non-shockable rhythm)
PEA is recognised at the bedside, never from the strip alone. This is exam practice, not clinical guidance.
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