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 behaviour shows active listening?
AChanging the subject when emotions come up
BParaphrasing what the patient said to check understanding
CPlanning your reply while the patient is talking
DLooking at the computer screen to take notes during the conversation
2.Nursing fundamentalsHard
A patient has a platelet count of 40 × 10⁹/L (40,000/mm³). Which nursing measure is appropriate?
AGive aspirin for any headaches
BUse a soft toothbrush and avoid IM injections where possible
CEncourage contact sports to raise the count
DUse a firm toothbrush and floss hard to keep the gums healthy
3.Infection control & patient safetyMedium
A patient on nasal cannula oxygen has dry lips. Which product should the nurse offer?
AA scented petroleum ointment
BAn oil-based lip balm
CPetroleum jelly
DA water-based lip lubricant
4.Infection control & patient safetyHard
During a procedure, a nurse sees that the team is about to start without a time-out. What should the nurse do?
ASpeak up clearly and stop the start until the time-out is done
BReport it to the manager at the end of the week
CSay nothing, because the surgeon is responsible for the procedure
DWait and raise the issue after the procedure is finished
5.Prioritization & delegationMedium
A patient has taken prednisone (prednisolone in many countries) for several months. Which statement shows a need for further teaching?
A“I will take the tablets with food.”
B“I will stop the tablets as soon as I feel better.”
C“I will tell my dentist and other doctors that I take a steroid.”
D“I will report signs of infection early.”
6.Prioritization & delegationHard
After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?
AInserting a tube or suction catheter through the nose
BPlacing a loose gauze under the nose
CInforming the provider about the drainage
DChecking the fluid for glucose or a halo sign on gauze
7.Clinical nursingMedium
A patient's fluid balance chart shows intake of 1,200 mL and output of 2,300 mL over 24 hours. What does this indicate?
AA balanced fluid status
BA negative fluid balance of 1,100 mL
CA positive fluid balance of 1,100 mL
DA positive fluid balance of 3,500 mL
8.Clinical nursingHard
An older patient with a hip fracture becomes breathless and confused, with a petechial rash on the chest two days after injury. Which complication should be suspected?
ACompartment syndrome
BPressure ulcer
CUrinary tract infection
DFat embolism syndrome
9.Lab values & electrolytesMedium
Why must a blue-top (citrate) coagulation tube be filled to the correct level?
AUnderfilled tubes always give a falsely low hemoglobin and hematocrit
BThe laboratory charges extra when a tube is not filled correctly
CThe blood-to-anticoagulant ratio must be right for accurate clotting times
DAn overfull tube is needed to measure the potassium level
10.Lab values & electrolytesHard
An older adult has bone pain, fatigue and frequent infections. Results show anemia, a calcium of 12.4 mg/dL (3.1 mmol/L), a raised total protein and a rising creatinine. Which condition should be suspected?
AIron-deficiency anemia
BMultiple myeloma
CPrimary hypothyroidism
DAcute viral hepatitis
11.PharmacologyMedium
A patient takes regular paracetamol (acetaminophen) at home. Which teaching point best prevents accidental overdose?
AUse paracetamol only on an empty stomach
BTake paracetamol with alcohol to improve absorption
CCheck cold and flu remedies, as many also contain paracetamol
DTake an extra dose if the first one does not work within 10 minutes
12.PharmacologyHard
A patient on simvastatin is prescribed gemfibrozil. What is the main concern?
AA sharp rise in LDL cholesterol and triglycerides
BSevere hypoglycaemia
CLoss of all lipid-lowering effect
DA much higher risk of myopathy and rhabdomyolysis
13.Med-surg: cardiovascular & respiratoryMedium
Two days after a myocardial infarction, a patient develops sudden breathlessness, crackles and a new loud systolic murmur. Which complication should be suspected?
AA pulmonary embolism caused by prolonged bed rest
BPapillary muscle rupture with acute mitral regurgitation
CPost-infarction pericarditis causing a pericardial friction rub
DA new episode of stable angina brought on by stress
14.Med-surg: cardiovascular & respiratoryHard
A patient recovering from an MI is anxious about returning to normal life. Which intervention best supports recovery?
AAdvice to rest in bed for three months
BAdvice to stop tablets once they feel well
CReferral to cardiac rehabilitation
DAdvice to avoid all exercise permanently
15.Med-surg: neuro, endocrine & renalMedium
When a patient sticks out their tongue, it points to the right. Which nerve is affected?
AThe left hypoglossal nerve (XII)
BThe right hypoglossal nerve (XII)
CThe right facial nerve (VII)
DThe left trigeminal nerve (V)
16.Med-surg: neuro, endocrine & renalHard
A 22-year-old with type 1 diabetes has glucose 28 mmol/L, ketones 5.2 mmol/L, pH 7.10 and potassium 5.9 mmol/L. Which statement about potassium is correct?
ATotal-body potassium is high, so a potassium binder is needed now
BTotal-body potassium is low, and the level will fall with treatment
CPotassium need not be rechecked once insulin has been started
DThe insulin should be withheld to keep the potassium level stable
17.Med-surg: GI, perioperative & oncologyMedium
Which food advice reduces the risk of blockage with a new ileostomy?
AChew well, and bring in fibrous foods slowly
BEat plenty of nuts and seeds from day one
CDrink very little fluid to keep the output thick
DSwallow food quickly without chewing much
18.Med-surg: GI, perioperative & oncologyHard
A patient asks whether to take their usual bisoprolol on the morning of surgery. What is the usual guidance?
ATake a double dose to protect the heart
BStop it one week before any operation
CTake it only after the operation is finished
DUsually continue it with a sip of water, unless told otherwise
19.Maternity & obstetric nursingMedium
A labouring woman's tracing shows variable decelerations. Which action should the nurse take first?
APlace her flat on her back
BIncrease the oxytocin infusion
CChange the woman's position
DStart pushing efforts straight away
20.Maternity & obstetric nursingHard
A woman at 6 weeks has vaginal spotting and one-sided pelvic pain. Her hCG rose only slightly over 48 hours and no pregnancy is seen in the uterus on transvaginal ultrasound. What is the priority concern?
AA molar pregnancy
BA normal early pregnancy
CAn ectopic pregnancy
DA complete miscarriage with no further risk
21.Pediatric nursingMedium
Which signs suggest digoxin toxicity in a child?
AIncreased appetite, extra energy and rapid weight gain over a few days
BNausea, vomiting, poor feeding and a slow heart rate
CHigh fever with a spreading red rash
DFast heart rate with high blood pressure
22.Pediatric nursingHard
A child has had many hospital admissions with unexplained symptoms. They occur only when the mother is present and stop when the child is apart from her. What should the nurse consider?
AA rare genetic disorder that needs more tests at once
BThe child is pretending to be ill to avoid school
CFabricated or induced illness; follow safeguarding procedures
DThe ward environment or hospital food is causing the symptoms
23.Mental health nursingMedium
Which goal for a patient with depression is written in a SMART way?
A"The patient will be happier."
B"The patient will walk with staff for 15 minutes once a day by Friday."
C"The patient will improve her mood and sleep and start exercising more at some point."
D"The patient will feel better soon."
24.Mental health nursingHard
Which patient should the nurse see first?
AA newly admitted patient who says voices are telling him to jump out of the window
BA patient on lithium with a fine hand tremor
CAn anxious patient who wants to discuss discharge plans before the morning ward round
DA depressed patient who asks for help getting to sleep
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 1:40 PM. Which entry is the same time on the 24-hour clock? Click it.
1:40 PM
112:40
201:40
314:40
413:40
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 3 cups of tea, 6 fl oz of juice, 3 tsp of cough syrup. Using the equivalents given, find the total oral intake V in mL.
1 cup = 8 fl oz = 240 mL1 fl oz = 30 mL1 tsp = 5 mL
V = mL
27.Dosage calculationsMedium
A vial contains 1 g of powder. The label says: add 9.6 mL of water for injection to give a total volume of 10 mL. The prescription is 60 mg. What volume V of the reconstituted solution do you give?
1 g+ 9.6 mL → 10 mL60 mg
V = mL
28.Dosage calculationsHard
A patient is 147 cm tall and weighs 64 kg. The prescription is 250 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
147 cm64 kg250 mg/m²
D = mg
29.IV infusion ratesMedium
An infusion is ordered at 50 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
50 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
100 mg of a drug is diluted in 100 mL and given by gravity through a set of 60 gtt/mL. The order is 50 mg per hour. Find the drip rate R in drops per minute.
100 mg/100 mL50 mg/h60 gtt/mL
R = gtt/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 14 units/kg/h for a patient who weighs 110 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL14 units/kg/h110 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 26 mL/h. The patient weighs 105 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL26 mL/h105 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 74 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
74 kg8 hurine: 150 mLurine: 300 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 11:15 and runs by pump at 80 mL/h. How many mL V are left in the bag at 16:15?
1000 mL80 mL/h11:15 → 16:15
V = mL
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: no; secondary diagnosis: no; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; 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 48 kg and is 158 cm tall. Calculate the BMI and click the WHO weight category.
48 kg158 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 7.23, PaCO₂ 27 mmHg (3.6 kPa) and HCO₃⁻ 11 mmol/L. The primary disorder is metabolic acidosis. How far is it compensated? Click your answer.
pH 7.23PaCO₂ 27 mmHg (3.6 kPa)HCO₃⁻ 11 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 36 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 36 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Bazett’s formula QTc = QT/√RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
Identify the rhythm on this lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1asystole
2ventricular fibrillation
3junctional rhythm
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: B · Paraphrasing what the patient said to check understanding
Why this is the answer
Active listening includes attention, appropriate eye contact, nodding, reflecting and paraphrasing. It helps patients feel heard and gives the nurse accurate information.
Answer
B · Paraphrasing what the patient said to check understanding
2.Nursing fundamentals
Answer: B · Use a soft toothbrush and avoid IM injections where possible
Why this is the answer
A low platelet count raises the risk of bleeding. Bleeding precautions include soft toothbrushes, electric razors, avoiding IM injections and avoiding aspirin and NSAIDs.
Answer
B · Use a soft toothbrush and avoid IM injections where possible
3.Infection control & patient safety
Answer: D · A water-based lip lubricant
Why this is the answer
Petroleum- and oil-based products can increase the risk of burns or fire in an oxygen-rich setting. A water-based lubricant is used instead.
Answer
D · A water-based lip lubricant
4.Infection control & patient safety
Answer: A · Speak up clearly and stop the start until the time-out is done
Why this is the answer
The time-out is a key step to prevent wrong-patient, wrong-site and wrong-procedure errors. Any team member who sees it being skipped should speak up and halt the procedure until it is done.
Answer
A · Speak up clearly and stop the start until the time-out is done
5.Prioritization & delegation
Answer: B · “I will stop the tablets as soon as I feel better.”
Why this is the answer
Stopping long-term corticosteroids suddenly can cause adrenal crisis, so they are tapered as prescribed. Taking them with food, telling other prescribers and reporting infection are correct.
Answer
B · “I will stop the tablets as soon as I feel better.”
6.Prioritization & delegation
Answer: A · Inserting a tube or suction catheter through the nose
Why this is the answer
Clear nasal drainage after a head injury can be cerebrospinal fluid from a basal skull fracture. Nasal tubes could enter the brain and introduce infection, so they are avoided.
Answer
A · Inserting a tube or suction catheter through the nose
7.Clinical nursing
Answer: B · A negative fluid balance of 1,100 mL
Why this is the answer
1,200 − 2,300 = −1,100 mL. A negative balance means more fluid is lost than gained, which may cause dehydration.
Answer
B · A negative fluid balance of 1,100 mL
8.Clinical nursing
Answer: D · Fat embolism syndrome
Why this is the answer
Fat embolism typically appears 24–72 hours after a long-bone or pelvic fracture, with the triad of respiratory distress, neurological changes and a petechial rash.
Answer
D · Fat embolism syndrome
9.Lab values & electrolytes
Answer: C · The blood-to-anticoagulant ratio must be right for accurate clotting times
Why this is the answer
Citrate tubes contain a set volume of anticoagulant. If the tube is underfilled, the extra citrate falsely prolongs the PT and aPTT, so the laboratory may reject the sample.
Answer
C · The blood-to-anticoagulant ratio must be right for accurate clotting times
10.Lab values & electrolytes
Answer: B · Multiple myeloma
Why this is the answer
Multiple myeloma typically causes high calcium from bone destruction, kidney damage, anemia and bone lesions, plus a raised protein from a monoclonal antibody. Recurrent infections reflect poor production of normal antibodies.Checked against:Multiple Myeloma · StatPearls (NCBI Bookshelf) (2023)
Answer
B · Multiple myeloma
11.Pharmacology
Answer: C · Check cold and flu remedies, as many also contain paracetamol
Why this is the answer
Many combination products contain paracetamol, so a patient can take too much without realising. Regular alcohol use and liver disease also increase the risk of liver damage.
Answer
C · Check cold and flu remedies, as many also contain paracetamol
12.Pharmacology
Answer: D · A much higher risk of myopathy and rhabdomyolysis
Why this is the answer
Gemfibrozil reduces statin clearance and adds its own muscle toxicity. The combination greatly increases the risk of rhabdomyolysis and is generally avoided.
Answer
D · A much higher risk of myopathy and rhabdomyolysis
13.Med-surg: cardiovascular & respiratory
Answer: B · Papillary muscle rupture with acute mitral regurgitation
Why this is the answer
Rupture of a papillary muscle (or of the ventricular septum) after MI produces a new murmur and sudden heart failure or shock. This is a surgical emergency. Pericarditis causes pleuritic chest pain and a friction rub rather than acute pulmonary oedema with a new murmur.
Answer
B · Papillary muscle rupture with acute mitral regurgitation
14.Med-surg: cardiovascular & respiratory
Answer: C · Referral to cardiac rehabilitation
Why this is the answer
Cardiac rehabilitation combines supervised exercise, risk factor education, medication advice and psychological support. It improves quality of life and reduces cardiovascular mortality and readmissions. Patients are encouraged to return gradually to activity, including work, driving and sex, according to advice.
Answer
C · Referral to cardiac rehabilitation
15.Med-surg: neuro, endocrine & renal
Answer: B · The right hypoglossal nerve (XII)
Why this is the answer
With a lower motor neuron lesion of the hypoglossal nerve, the tongue deviates towards the side of the lesion, because the healthy muscles push it across. Wasting and fasciculation of that side may also be seen.
Answer
B · The right hypoglossal nerve (XII)
16.Med-surg: neuro, endocrine & renal
Answer: B · Total-body potassium is low, and the level will fall with treatment
Why this is the answer
In DKA, potassium moves out of cells while the kidneys lose it in the urine, so serum potassium can be normal or high despite a large total deficit. Fluids and insulin lower it quickly. Potassium is monitored closely and replaced once it falls into the normal range, as per protocol.
Answer
B · Total-body potassium is low, and the level will fall with treatment
17.Med-surg: GI, perioperative & oncology
Answer: A · Chew well, and bring in fibrous foods slowly
Why this is the answer
Fibrous foods such as nuts, sweetcorn, dried fruit and fruit skins can form a bolus that blocks the narrow stoma. Chewing thoroughly, introducing these foods slowly and drinking enough fluid reduce the risk. Symptoms of blockage include cramping, a swollen stoma and no output.
Answer
A · Chew well, and bring in fibrous foods slowly
18.Med-surg: GI, perioperative & oncology
Answer: D · Usually continue it with a sip of water, unless told otherwise
Why this is the answer
Beta-blockers are usually continued around surgery because sudden withdrawal can cause rebound tachycardia and ischaemia. The patient follows the specific instructions from the preoperative assessment.
Answer
D · Usually continue it with a sip of water, unless told otherwise
19.Maternity & obstetric nursing
Answer: C · Change the woman's position
Why this is the answer
Repositioning (side to side, or hands and knees) often relieves cord compression. If the decelerations persist, the provider is notified. Lying flat adds caval compression.
Answer
C · Change the woman's position
20.Maternity & obstetric nursing
Answer: C · An ectopic pregnancy
Why this is the answer
A slowly rising hCG with an empty uterus at a level where a sac should be seen suggests an ectopic pregnancy. Rupture can cause life-threatening bleeding, so she needs close monitoring and urgent review.
Answer
C · An ectopic pregnancy
21.Pediatric nursing
Answer: B · Nausea, vomiting, poor feeding and a slow heart rate
Why this is the answer
Early signs of digoxin toxicity in children include anorexia, nausea, vomiting and bradycardia or other arrhythmias. Low potassium increases the risk of toxicity, so potassium levels are monitored.
Answer
B · Nausea, vomiting, poor feeding and a slow heart rate
22.Pediatric nursing
Answer: C · Fabricated or induced illness; follow safeguarding procedures
Why this is the answer
Fabricated or induced illness (formerly Munchausen syndrome by proxy) is a form of abuse in which a carer invents or causes illness. Careful objective documentation and early involvement of the safeguarding team are essential; the carer should not be confronted alone.
Answer
C · Fabricated or induced illness; follow safeguarding procedures
23.Mental health nursing
Answer: B · "The patient will walk with staff for 15 minutes once a day by Friday."
Why this is the answer
A SMART goal states exactly what the patient will do, how much and by when, so that progress can be evaluated. Vague goals cannot be measured.
Answer
B · "The patient will walk with staff for 15 minutes once a day by Friday."
24.Mental health nursing
Answer: A · A newly admitted patient who says voices are telling him to jump out of the window
Why this is the answer
Command hallucinations to self-harm indicate an immediate safety risk. A fine tremor is a common lithium side effect, and the other requests can wait briefly.
Answer
A · A newly admitted patient who says voices are telling him to jump out of the window
25.Nursing math & unit conversions
Answer: 13:40
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
1 PM → 1 + 12 = 13
Answer
13:40
Answer
13:40
26.Nursing math & unit conversions
Answer: V = 915 mL
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.
Each item in mL
3 cups = 3·240 = 720 mL
6 fl oz = 6·30 = 180 mL
3 tsp = 3·5 = 15 mL
Add
V = 720 + 180 + 15 = 915 mL
Answer
V = 915 mL
27.Dosage calculations
Answer: V = 0.6 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.
Concentration after mixing
1000 mg/10 mL = 100 mg/mL
Volume
V = 60/100 = 0.6 mL
Answer
V = 0.6 mL
28.Dosage calculations
Answer: D = 404.1 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 = √(147·64/3600) = √2.613 = 1.617 m²
Dose
D = 250·1.617 = 404.1 mg
Answer
D = 404.1 mg
29.IV infusion rates
Answer: R = 50 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Millilitres per minute
50/60 = 0.8333 mL/min
Drip rate
R = 0.8333·60 = 50 gtt/min
Answer
R = 50 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: R = 50 gtt/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
100/100 = 1 mg/mL
Volume per hour
50/1 = 50 mL/h
Drip rate
R = 50·60/60 = 50 gtt/min
Answer
R = 50 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 15.4 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
14·110 = 1 540 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1540/100 = 15.4 mL/h
Answer
R = 15.4 mL/h
32.Pediatric & critical-care dosing
Answer: D = 4.1 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
26·1000 = 26000 mcg/h
26000/60 = 433.3 mcg/min
Per kilogram
D = 433.3/105 = 4.127 ≈ 4.1 mcg/kg/min
Answer
D = 4.1 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 0.76 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
150 + 300 = 450 mL
Per kilogram per hour
U = 450/(74·8) = 0.7601 ≈ 0.76 mL/kg/h
Answer
U = 0.76 mL/kg/h
34.IV fluids & fluid balance
Answer: V = 600 mL
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Elapsed time
11:15 → 16:15 = 5 h
Volume infused
80·5 = 400 mL
Volume left
V = 1000 − 400 = 600 mL
Answer
V = 600 mL
35.Clinical assessment scores
Answer: MFS = 35
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: no → 0
secondary diagnosis: no → 0
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: yes → 20
gait: normal, bed rest or wheelchair → 0
mental status: knows own limits → 0
Add
Morse total = 0 + 0 + 15 + 20 + 0 + 0 = 35
Answer
MFS = 35
36.Clinical assessment scores
Answer: healthy weight
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 = 48/1.58² = 19.23
Category
healthy weight
Answer
healthy weight
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 7.23: acidaemia (below 7.35)
PaCO₂ 27 mmHg: low (35–45)
HCO₃⁻ 11 mmol/L: low (22–26)
Compensation
Clinically, also check the expected compensation: Winter’s formula expects PaCO₂ 22.5–26.5 mmHg, so the measured 27 mmHg points to an additional respiratory acidosis (a mixed disorder). The answer above is the ROME exam classification.
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 46.2 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
0.7·36 + 21 = 46.2 mmHg
Answer
PaCO₂ = 46.2 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: QTc = 0.417 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 10 × 0.04 = 0.40 s
RR = 23 × 0.04 = 0.92 s
Bazett’s formula
QTc = 0.40/√0.92 = 0.40/0.9592 = 0.417 s
Answer
QTc = 0.417 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (417 ms)
40.ECG rhythm strip interpretation
Answer: asystole
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
Five steps
1. Rate: no countable ventricular rate.
2. Rhythm: none; an almost flat line.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: no QRS complexes.
Interpretation
asystole
Answer
asystole
A flat line is always checked: look at the patient, the leads and the gain, and view a second lead, because a loose electrode or fine VF can look like asystole.
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