Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
Which patient is at greatest risk of injury from a heat pack?
AA patient with period pain
BA patient with reduced sensation from diabetic neuropathy
CA young adult with a stiff neck after sleeping in an awkward position
DA patient with a sore lower back after gardening
2.Nursing fundamentalsHard
Which nursing diagnosis is written in the problem–aetiology–signs (PES) format?
AImpaired skin integrity related to immobility, as shown by a sacral wound
BPain related to pain, as shown by the patient saying that it hurts a lot
CPneumonia related to a bacterial infection in the right lung
DTurn the patient every two hours to protect the skin
3.Infection control & patient safetyMedium
A patient wants to use their own electric hair dryer in the hospital. What is correct?
AIt can be used straight away if it looks new
BIt can be plugged into an extension lead under the bed
CIt is checked for electrical safety according to hospital policy before use
DIt can be used in the bathroom near the sink if the patient is careful
4.Infection control & patient safetyHard
A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?
AYes, near misses are reported so system weaknesses can be fixed
BOnly if the same error happens three times
CNo, because reporting near misses only blames the pharmacy staff for nothing
DNo, because the patient was not harmed
5.Prioritization & delegationMedium
Which two patients can most safely share a room?
AA patient with chickenpox and a patient on chemotherapy
BTwo patients who both have C. difficile infection
CA patient with MRSA in a wound and a patient after surgery
DA patient with influenza and a patient with COPD
6.Prioritization & delegationHard
After surgery, a patient who has taken long-term steroids becomes hypotensive and weak, and the blood pressure does not rise with IV fluids. Which problem should the nurse suspect?
AAn allergic reaction to the anesthetic
BNormal tiredness after anesthesia
CFluid overload from too much IV fluid
DAdrenal crisis from steroid withdrawal
7.Clinical nursingMedium
A patient's seizure has lasted more than five minutes. What does this mean?
ARestrain the limbs to stop the movements
BIt should be treated as status epilepticus and emergency medication given
CIt is normal and needs no treatment
DPlace something in the mouth to prevent tongue biting
8.Clinical nursingHard
Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?
AIntramuscular injection into the anterolateral thigh
BSubcutaneous injection into the upper arm
CIntravenous bolus given by the nurse without monitoring
DOral tablet dissolved under the tongue
9.Lab values & electrolytesMedium
A woman with hyperemesis gravidarum has vomited for 3 days. Which urine finding would the nurse expect?
ABilirubin
BRed cell casts
CKetones
DNitrites
10.Lab values & electrolytesHard
The nurse teaches a patient who is collecting a 24-hour urine sample at home. Which statement shows a need for further teaching?
A"If I forget to save one void, I'll just carry on to the end"
B"I'll keep the container cool as the laboratory told me to"
C"I'll ask whether any foods or drugs should be avoided first"
D"I'll empty my bladder at the end time and add that urine"
11.PharmacologyMedium
Why should a patient rinse the mouth after using an inhaled corticosteroid?
ATo stop the drug being absorbed too quickly into the blood
BTo make the drug work faster in the lungs
CTo prevent a fall in blood glucose
DTo reduce the risk of oral thrush (candidiasis) and hoarseness
12.PharmacologyHard
A ventilated ICU patient receives vecuronium, a neuromuscular blocker. Why must sedation and pain relief also be given?
AVecuronium stops working unless a sedative is also given
BSedatives are needed to prevent vecuronium from causing seizures and agitation
CNeuromuscular blockers paralyse muscles but do not cause sedation or analgesia
DVecuronium causes severe pain at the injection site
13.Med-surg: cardiovascular & respiratoryMedium
Why must anti-embolism stockings be measured and fitted correctly?
APoorly fitting stockings can cause pressure damage
BCorrect fit is needed only to improve the appearance
CLoose stockings make the patient's legs too warm at night
DTight stockings work better, so the smallest size is always best
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?
ALeave it, because a collapsing bag shows a good seal
BCheck the oxygen supply and flow so the bag stays inflated
CReduce the flow to 2 L/min to stop the bag collapsing
DRemove the bag, as the mask works without it
15.Med-surg: neuro, endocrine & renalMedium
Which side effects are common with oxybutynin for an overactive bladder?
ADry mouth and constipation
BA cough and a raised potassium
CWeight loss and a fast tremor
DDiarrhoea and heavy sweating
16.Med-surg: neuro, endocrine & renalHard
Which statement correctly distinguishes spinal shock from neurogenic shock?
ASpinal shock is low blood pressure; neurogenic shock is the loss of reflexes
BNeurogenic shock is caused by blood loss; spinal shock is caused by infection
CSpinal shock is lost reflexes; neurogenic shock is low BP and slow pulse
DThey are two names for exactly the same condition
17.Med-surg: GI, perioperative & oncologyMedium
A patient with an ileal conduit (urostomy) is worried about mucus in the urine. What is the correct explanation?
AIt is normal, as the conduit is made from small bowel
BIt means the stoma is failing and needs surgery
CIt shows a bowel obstruction is developing
DIt is a sign of a kidney stone and must be reported today
18.Med-surg: GI, perioperative & oncologyHard
A nurse finds a dislodged sealed radiation source in the bed of a patient receiving brachytherapy. What should the nurse do?
AThrow it in the clinical waste bag
BUse long-handled forceps to put it in the lead container; report it
CPick it up with gloved hands and put it in the nearest sharps bin quickly
DLeave it in the bed until the end of the shift
19.Maternity & obstetric nursingMedium
A labouring woman's tracing shows variable decelerations. Which action should the nurse take first?
AChange the woman's position
BIncrease the oxytocin infusion
CStart pushing efforts straight away
DPlace her flat on her back
20.Maternity & obstetric nursingHard
Shortly after an epidural is started, a labouring woman's blood pressure falls to 86/50 mmHg and the fetal heart rate drops. What should the nurse do first?
AAsk her to walk around the room
BIncrease the epidural infusion rate
CRaise the head of the bed to a high sitting position to improve her breathing
DTurn her onto her side to move the uterus off the large vessels
21.Pediatric nursingMedium
How should an infant with heart failure be fed?
ALying flat on the back so the baby does not need to hold the head up
BLarge feeds every 6 hours so the baby can rest in between
CStop the feed when the baby tires and wait until the next scheduled feed
DSmall, frequent feeds with rest breaks, using higher-energy milk if prescribed
22.Pediatric nursingHard
Which bedside check is recommended before each feed to confirm the position of a child's nasogastric tube?
AAsk the child whether the tube feels comfortable and check the length mark only
BPlace the end of the tube in water and look for bubbles
CCheck that aspirate from the tube is acidic, using the pH limit in local policy
DInject air and listen over the stomach for a "whoosh"
23.Mental health nursingMedium
A woman was assaulted 10 days ago. She has nightmares, avoids the area and feels detached. According to DSM-5, which diagnosis fits the timing best?
APost-traumatic stress disorder
BGeneralised anxiety disorder
CAdjustment disorder with anxiety
DAcute stress disorder
24.Mental health nursingHard
A patient taking valproate has severe abdominal pain spreading to her back, with nausea and vomiting. What should the nurse suspect?
ASerotonin syndrome
BLithium toxicity
CPancreatitis
DSimple indigestion
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for an injection gives 1.2987 mL. The rule in this exercise is that volumes of 1 mL or more are rounded to the nearest tenth of a mL. What value x do you record?
1.2987 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 22:10 and finishes at 01:55 the next morning (24-hour clock). How many hours t did it run? Give the answer in hours as a decimal, rounded to two decimal places.
22:1001:55
t = h
27.Dosage calculationsMedium
A patient weighs 15 kg. The prescribed dose is 10 mg/kg per day, given in 4 equal doses. How many milligrams D are given per dose?
15 kg10 mg/kg/day4× per day
D = mg
28.Dosage calculationsHard
A patient is 189 cm tall and weighs 91 kg. The prescription is 135 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
189 cm91 kg135 mg/m²
D = mg
29.IV infusion ratesMedium
Infuse 500 mL over 3 hours with a giving set of 15 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL3 h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 400 mg in 500 mL runs at 3 mL/h. How many micrograms per minute D does the patient receive?
400 mg/500 mL3 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 18 units/kg/h for a patient who weighs 53 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL18 units/kg/h53 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 79 kg has an order for nitroglycerin at 15 mcg/min. The bag contains 50 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
50 mg/250 mL15 mcg/min79 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
milk: 100 mLwater: 120 mLjelly: 120 mLIV infusion: 75 mL/h × 12 hIV antibiotic: 2 × 50 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 06:30 and runs by pump at 120 mL/h. How many mL V are left in the bag at 07:30?
500 mL120 mL/h06:30 → 07:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 10, with E3 and V4. What motor score M was recorded, and which response does it describe? Give the number.
GCS 10E3V4
M =
36.Clinical assessment scoresHard
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: none, bed rest or nurse assists; IV therapy or saline lock: no; gait: normal, bed rest or wheelchair; mental status: overestimates or forgets limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 20 mmHg (2.7 kPa). Use the rule that in chronic respiratory alkalosis HCO₃⁻ falls by 5 mmol/L for every 10 mmHg that PaCO₂ is below 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a metabolic acidosis: pH 7.24, PaCO₂ 43 mmHg (5.7 kPa), HCO₃⁻ 18 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.24PaCO₂ 43 mmHg (5.7 kPa)HCO₃⁻ 18 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
39.ECG rhythm strip interpretationMedium
Interpret this lead II rhythm strip. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1normal sinus rhythm
2first-degree AV block
3junctional rhythm
4sinus tachycardia
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1sinus rhythm with wide QRS
2third-degree (complete) AV block
3paced rhythm, failure to capture
4dual-chamber (AV) paced rhythm
3Solutions
1.Nursing fundamentals
Answer: B · A patient with reduced sensation from diabetic neuropathy
Why this is the answer
Patients who cannot feel heat properly, such as those with neuropathy, spinal injury or reduced consciousness, can be burned without noticing. Their skin needs extra checks or heat should be avoided.
Answer
B · A patient with reduced sensation from diabetic neuropathy
2.Nursing fundamentals
Answer: A · Impaired skin integrity related to immobility, as shown by a sacral wound
Why this is the answer
A PES statement gives the nursing problem, the related cause and the defining signs. Pneumonia is a medical diagnosis, turning is an intervention, and a cause cannot repeat the problem.
Answer
A · Impaired skin integrity related to immobility, as shown by a sacral wound
3.Infection control & patient safety
Answer: C · It is checked for electrical safety according to hospital policy before use
Why this is the answer
Electrical items from home can be faulty and cause shocks or fires. Policies usually require them to be inspected before use, and extension cords near patients are avoided.
Answer
C · It is checked for electrical safety according to hospital policy before use
4.Infection control & patient safety
Answer: A · Yes, near misses are reported so system weaknesses can be fixed
Why this is the answer
Near misses show where errors can slip through and are reported in the same way as errors that reach the patient. Learning from them prevents future harm.
Answer
A · Yes, near misses are reported so system weaknesses can be fixed
5.Prioritization & delegation
Answer: B · Two patients who both have C. difficile infection
Why this is the answer
Cohorting patients with the same organism is acceptable when single rooms are not available. The other pairs would expose a vulnerable patient to an infection.
Answer
B · Two patients who both have C. difficile infection
6.Prioritization & delegation
Answer: D · Adrenal crisis from steroid withdrawal
Why this is the answer
Patients on long-term steroids may not make enough cortisol to cope with surgical stress. Refractory hypotension suggests adrenal crisis, which needs urgent IV hydrocortisone as prescribed.
Answer
D · Adrenal crisis from steroid withdrawal
7.Clinical nursing
Answer: B · It should be treated as status epilepticus and emergency medication given
Why this is the answer
A seizure lasting five minutes or longer, or repeated seizures without recovery, is treated as status epilepticus. Protect from injury, give oxygen and give emergency anticonvulsants as prescribed.
Answer
B · It should be treated as status epilepticus and emergency medication given
8.Clinical nursing
Answer: A · Intramuscular injection into the anterolateral thigh
Why this is the answer
IM adrenaline into the outer thigh is absorbed quickly and is the first-line route. IV adrenaline is reserved for experienced specialists with full monitoring because of the risk of arrhythmias.
Answer
A · Intramuscular injection into the anterolateral thigh
9.Lab values & electrolytes
Answer: C · Ketones
Why this is the answer
Prolonged vomiting and poor intake lead to fat breakdown and ketonuria, along with dehydration and electrolyte loss such as hypokalemia. Urine ketones help assess severity and response to IV fluids and antiemetics.Checked against:Ketones urine test · MedlinePlus (NIH) (2025)
Answer
C · Ketones
10.Lab values & electrolytes
Answer: A · "If I forget to save one void, I'll just carry on to the end"
Why this is the answer
A 24-hour collection is valid only if every void in the period is saved; if a void is lost, the nurse or clinic is told and the collection is usually restarted. Keeping the container cool as instructed, adding the final void at the end time and asking about restrictions are correct.Checked against:Urine 24-hour volume · MedlinePlus (NIH) (2025)
Answer
A · "If I forget to save one void, I'll just carry on to the end"
11.Pharmacology
Answer: D · To reduce the risk of oral thrush (candidiasis) and hoarseness
Why this is the answer
Steroid left in the mouth and throat suppresses local immunity and can cause candidiasis and a hoarse voice. Rinsing and spitting, and using a spacer, reduce this risk.
Answer
D · To reduce the risk of oral thrush (candidiasis) and hoarseness
12.Pharmacology
Answer: C · Neuromuscular blockers paralyse muscles but do not cause sedation or analgesia
Why this is the answer
Neuromuscular blockers cause paralysis but leave awareness and pain sensation intact. Without sedation and analgesia, the patient could be awake and in pain while unable to move.
Answer
C · Neuromuscular blockers paralyse muscles but do not cause sedation or analgesia
13.Med-surg: cardiovascular & respiratory
Answer: A · Poorly fitting stockings can cause pressure damage
Why this is the answer
Stockings that are the wrong size or that roll down can act like a tourniquet and cause skin and pressure damage. They are measured to the leg, checked daily, and avoided in significant peripheral arterial disease, severe neuropathy or leg skin damage.
Answer
A · Poorly fitting stockings can cause pressure damage
14.Med-surg: cardiovascular & respiratory
Answer: B · 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
B · Check the oxygen supply and flow so the bag stays inflated
15.Med-surg: neuro, endocrine & renal
Answer: A · Dry mouth and constipation
Why this is the answer
Oxybutynin blocks muscarinic receptors, causing dry mouth, constipation, blurred vision, urinary retention and, especially in older adults, confusion. Newer agents may have fewer effects on the brain.
Answer
A · Dry mouth and constipation
16.Med-surg: neuro, endocrine & renal
Answer: C · Spinal shock is lost reflexes; neurogenic shock is low BP and slow pulse
Why this is the answer
Spinal shock is the temporary loss of reflexes and tone below the injury. Neurogenic shock is hypotension and bradycardia caused by loss of sympathetic tone, usually with injuries at T6 or above. The two can occur together.
Answer
C · Spinal shock is lost reflexes; neurogenic shock is low BP and slow pulse
17.Med-surg: GI, perioperative & oncology
Answer: A · It is normal, as the conduit is made from small bowel
Why this is the answer
An ileal conduit uses a segment of ileum, which continues to produce mucus. Patients are encouraged to drink well to keep the urine flowing. Cloudy, offensive urine with fever, however, suggests infection.
Answer
A · It is normal, as the conduit is made from small bowel
18.Med-surg: GI, perioperative & oncology
Answer: B · Use long-handled forceps to put it in the lead container; report it
Why this is the answer
A dislodged source is picked up with long-handled forceps and placed in the shielded container kept in the room. The radiation safety officer and team are informed, following local policy.
Answer
B · Use long-handled forceps to put it in the lead container; report it
19.Maternity & obstetric nursing
Answer: A · 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
A · Change the woman's position
20.Maternity & obstetric nursing
Answer: D · Turn her onto her side to move the uterus off the large vessels
Why this is the answer
A lateral position relieves aortocaval compression and improves venous return and placental flow. Then increase IV fluids as ordered, notify the anaesthetist or provider and give a vasopressor if prescribed.
Answer
D · Turn her onto her side to move the uterus off the large vessels
21.Pediatric nursing
Answer: D · Small, frequent feeds with rest breaks, using higher-energy milk if prescribed
Why this is the answer
Infants with heart failure use a lot of energy and tire easily. Small, frequent feeds, rest breaks, a semi-upright position and energy-dense milk help them grow; tube feeding may be needed if they cannot take enough.
Answer
D · Small, frequent feeds with rest breaks, using higher-energy milk if prescribed
22.Pediatric nursing
Answer: C · Check that aspirate from the tube is acidic, using the pH limit in local policy
Why this is the answer
Testing the pH of aspirate is the recommended bedside check before each use in many guidelines (UK NHS guidance uses a pH of 5.5 or below). An X-ray is the most reliable method and is used to confirm initial placement in many settings, including most US hospitals, or when no suitable aspirate is obtained. The air "whoosh" and bubble tests are unreliable and can miss a tube in the lungs.
Answer
C · Check that aspirate from the tube is acidic, using the pH limit in local policy
23.Mental health nursing
Answer: D · Acute stress disorder
Why this is the answer
Acute stress disorder lasts from 3 days to 1 month after a trauma. If symptoms last longer than 1 month, PTSD is diagnosed. ICD-11 does not have this diagnosis and describes an acute stress reaction as a normal response rather than a disorder.
Answer
D · Acute stress disorder
24.Mental health nursing
Answer: C · Pancreatitis
Why this is the answer
Valproate can cause acute pancreatitis, which can be life-threatening. Severe abdominal pain with vomiting must be reported promptly so the drug can be stopped and the patient assessed.
Answer
C · Pancreatitis
25.Nursing math & unit conversions
Answer: x = 1.3 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 tenths place
1.2987 → 2
Only the next digit decides
1.2987 → 9
9 is 5 or more, so round 2 up.
The digits after it (87) are ignored: round once, never step by step.
Round
x = 1.3 mL
Answer
x = 1.3 mL
26.Nursing math & unit conversions
Answer: t = 3.75 h
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.
Before midnight
22:10 → 24:00 = 110 min
After midnight
00:00 → 01:55 = 115 min
Total
110 + 115 = 225 min
t = 225/60 = 3.75 h
Answer
t = 3.75 h
27.Dosage calculations
Answer: D = 37.5 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
10·15 = 150 mg
Per dose
D = 150/4 = 37.5 mg
Answer
D = 37.5 mg
28.Dosage calculations
Answer: D = 295.1 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 = √(189·91/3600) = √4.777 = 2.186 m²
Dose
D = 135·2.186 = 295.1 mg
Answer
D = 295.1 mg
29.IV infusion rates
Answer: R = 42 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 = 500·15/180 = 41.67 ≈ 42 gtt/min
Answer
R = 42 gtt/min
At the bedside you round to the nearest whole drop: 42 gtt/min.
30.IV infusion rates
Answer: D = 40 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
400000 mcg/500 mL = 800 mcg/mL
Dose per hour
3·800 = 2400 mcg/h
Dose per minute
D = 2400/60 = 40 mcg/min
Answer
D = 40 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 9.5 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
18·53 = 954 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 954/100 = 9.54 ≈ 9.5 mL/h
Answer
R = 9.5 mL/h
32.Pediatric & critical-care dosing
Answer: R = 4.5 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
50 000/250 = 200 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
15·60 = 900 mcg/h
Pump rate
R = 900/200 = 4.5 mL/h
Answer
R = 4.5 mL/h
33.IV fluids & fluid balance
Answer: I = 1340 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 + 120 + 120 = 340 mL
IV infusion: 75·12 = 900 mL
IV antibiotic: 2·50 = 100 mL
I = 1340 mL
Answer
I = 1340 mL
34.IV fluids & fluid balance
Answer: V = 380 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
06:30 → 07:30 = 1 h
Volume infused
120·1 = 120 mL
Volume left
V = 500 − 120 = 380 mL
Answer
V = 380 mL
35.Clinical assessment scores
Answer: M = 3
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.
Motor score
M = 10 − 3 − 4 = 3
M3: abnormal flexion of the arms (decorticate posture)
Answer
M = 3
36.Clinical assessment scores
Answer: low risk
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: none, bed rest or nurse assists → 0
IV therapy or saline lock: no → 0
gait: normal, bed rest or wheelchair → 0
mental status: overestimates or forgets limits → 15
Add
Morse total = 0 + 0 + 0 + 0 + 0 + 15 = 15
Risk level
15 → low risk
Answer
low risk
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 14 mmol/L
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Change in PaCO₂
|20 − 40| = 20 mmHg → 2 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 − 5·2 = 14 mmol/L
Answer
HCO₃⁻ = 14 mmol/L
38.Arterial blood gas interpretation
Answer: added respiratory acidosis
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
1.5·18 + 8 = 35 → 33–37 mmHg
Compare
measured: 43 mmHg → added respiratory acidosis
Answer
added respiratory acidosis
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 = 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: 0.30 s, constant, longer than 0.20 s.
5. QRS: 0.10 s, narrow (below 0.12 s).
Interpretation
first-degree AV block
Answer
first-degree AV block
40.ECG rhythm strip interpretation
Answer: dual-chamber (AV) paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 21 small boxes, 1500 ÷ 21 ≈ 71 per minute.
2. Rhythm: regular, every R–R is 0.84 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.16 s after the first one (the programmed AV delay).
5. QRS: 0.16 s, wide, right after the second spike (ventricular pacing).
Interpretation
dual-chamber (AV) paced rhythm
Answer
dual-chamber (AV) paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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