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
How should the heels of a bedbound patient at high risk be protected?
ALift them off the mattress with a pillow under the calves
BWrap them tightly in bandages
CRub them with cream several times a day
DRest them on a rolled towel placed directly under each heel
2.Nursing fundamentalsHard
A nurse has a needlestick injury from a used needle. What is the correct first action?
ASuck the wound to remove the blood
BLet it bleed freely, wash with soap and running water, then report it urgently
CFinish the shift and report it the next day
DScrub the area hard with a brush and alcohol, then report it at the end of the shift
3.Infection control & patient safetyMedium
A patient in bed has a generalized tonic-clonic seizure. What should the nurse do?
APut a padded tongue blade between the teeth to protect the tongue from biting
BTurn the patient on their side and protect them from injury without restraining
CHold the arms and legs firmly to stop the movements
DGive sips of water to keep the airway moist
4.Infection control & patient safetyHard
A handwritten order is hard to read, and the nurse is not sure of the drug name. What should the nurse do?
AHold the drug until the next day without telling anyone
BChoose the drug that seems most likely from the diagnosis
CAsk a colleague to guess what it says
DContact the prescriber to clarify before giving anything
5.Prioritization & delegationMedium
A nurse teaches foot care to a patient with diabetes. Which statement shows a need for further teaching?
A“I will soak my feet in hot water every evening.”
B“I will wear shoes that fit well, even at home.”
C“I will dry well between my toes after washing.”
D“I will check the soles of my feet every day with a mirror.”
6.Prioritization & delegationHard
A nurse is caring for four patients. Who can be safely assigned to the nursing assistant for routine care?
AA patient five days after a stroke who needs help with bathing and has stable vital signs
BA patient returning from surgery who needs the first postoperative assessment
CA patient with a new chest tube placed an hour ago
DA patient with a blood glucose of 52 mg/dL (2.9 mmol/L) who is sweating
7.Clinical nursingMedium
Long-term amiodarone treatment can affect which of the following?
AThyroid function, the lungs and the skin's sensitivity to sunlight
BThe sense of smell and taste only, with no other effects
CHair colour and nail growth only, with no effect on organs
DBlood glucose and cholesterol only
8.Clinical nursingHard
Why can pulse oximetry be misleading in carbon monoxide poisoning?
ACarbon monoxide only affects the heart rate reading
BThe oximeter overheats in smoke-exposed patients
CStandard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
DCarbon monoxide makes the oximeter read zero even in a well patient
9.Lab values & electrolytesMedium
A patient receiving chemotherapy has an ANC of 300/µL and a new temperature of 38.3 °C (100.9 °F). What should the nurse do first?
AReport it at once so cultures and antibiotics start quickly
BEncourage oral fluids and record the fever in the chart
CGive acetaminophen (paracetamol) and recheck the temperature in 4 hours
DRemove extra blankets and offer a tepid sponge bath
10.Lab values & electrolytesHard
A 68-year-old man has fatigue, a hemoglobin of 9.8 g/dL (98 g/L), an MCV of 72 fL and a low ferritin. He eats a normal diet. What is the most important next step?
AGive iron and do no further tests at all
BStart vitamin B12 injections
CRepeat the blood count in one year
DLook for a source of blood loss in the gut
11.PharmacologyMedium
A transplant patient takes tacrolimus. Which monitoring is most important?
AThyroid function and bone density
BSerum amylase
CBlood drug levels and kidney function
DPeak expiratory flow
12.PharmacologyHard
Why is pyridoxine (vitamin B6) often given together with isoniazid for tuberculosis?
ATo prevent liver damage from isoniazid
BTo increase the absorption of isoniazid
CTo reduce bacterial resistance
DTo prevent peripheral neuropathy
13.Med-surg: cardiovascular & respiratoryMedium
How big should a suction catheter be compared with the tracheostomy or endotracheal tube?
ANo more than half the internal diameter of the tube
BLarger than the tube, so that it clears it completely
CAny size, as the diameter does not matter
DExactly the same diameter as the tube, for a tight fit
14.Med-surg: cardiovascular & respiratoryHard
An adult inhales a peanut while laughing and now has a persistent cough and wheeze on one side. Where is the peanut most likely to have lodged?
AThe oesophagus
BThe left main bronchus
CThe right main bronchus
DThe nasal cavity
15.Med-surg: neuro, endocrine & renalMedium
A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?
ANausea, diarrhoea and a slow heart rate
BWeight gain, high glucose and swollen ankles
CDry mouth, constipation and a fast heart rate
DA persistent dry cough and a raised potassium
16.Med-surg: neuro, endocrine & renalHard
At 03:00 a patient's glucose is 3.6 mmol/L, but before breakfast it is high. They take a long-acting insulin in the evening. What should the nurse do?
ATreat the low and report the pattern so the evening dose is reviewed
BIgnore the night reading and act on the morning value only
CGive extra insulin at 03:00 because the morning value will be high
DStop all insulin permanently and monitor glucose four-hourly
17.Med-surg: GI, perioperative & oncologyMedium
Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?
ASlight hair thinning over months
BMild tiredness after a busy day
CNew diarrhoea or abdominal pain
DA small bruise after a knock
18.Med-surg: GI, perioperative & oncologyHard
After surgery, a patient keeps asking for analgesia before it is due, watches the clock and rates pain 8/10. What is the most appropriate interpretation?
AThe patient is addicted and should have analgesia withheld
BThe patient is exaggerating, so the pain scores should be ignored for now
CThe patient needs only distraction and no change in drugs
DPain may be undertreated; reassess and ask for a review of the plan
19.Maternity & obstetric nursingMedium
At station +2, where is the presenting part?
AFloating above the pelvic inlet
B2 cm below the ischial spines
CAt the level of the ischial spines
D2 cm above the ischial spines
20.Maternity & obstetric nursingHard
A baby was stillborn at 38 weeks. Which nursing action is most appropriate?
AOffer the parents time to see and hold their baby
BTell the parents they can try for another baby soon
CAvoid using the baby's name to prevent more grief
DRemove the baby quickly so the parents are not upset
21.Pediatric nursingMedium
Which is the main modifiable risk factor for type 2 diabetes in adolescents?
ABeing of a particular ethnic background
BObesity with low physical activity
CA family history of diabetes
DA viral infection in early childhood
22.Pediatric nursingHard
A 7-year-old with an asthma attack was wheezing loudly but is now quiet, drowsy and has very reduced air entry. What does this indicate?
AThe child is falling asleep normally
BA life-threatening deterioration with exhaustion and very poor air movement
CThe attack is resolving
DA good response to the reliever inhaler, with the airways now opening up again
23.Mental health nursingMedium
How does aripiprazole differ from most other antipsychotics?
AIt needs weekly white blood cell counts for safety
BIt has no effect on dopamine at all
CIt is a benzodiazepine with antipsychotic effects
DIt is a partial agonist at dopamine D2 receptors
24.Mental health nursingHard
A patient is found unresponsive with a respiratory rate of 6/min and pinpoint pupils. What should the nurse do first?
AGive flumazenil
BCall for help, open the airway and support breathing, and give naloxone as prescribed or per protocol
CGive a large glass of water
DPlace the patient in the recovery position and wait for the patient to wake up naturally before calling anyone
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 20:30 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
20:30
18:30 AM
28:30 PM
37:30 PM
410:30 PM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes ¾ cup of tea, 1 fl oz of juice, 4 tbsp of liquid supplement, 2 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 tbsp = 15 mL1 tsp = 5 mL
V = mL
27.Dosage calculationsMedium
A patient weighing 45 kg has a body surface area of 1.29 m². The prescription is 50 mg/m². Find the dose D in mg.
45 kgBSA = 1.29 m²50 mg/m²
D = mg
28.Dosage calculationsHard
The prescription is 3700 units of a drug that comes as 10000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
3700 units10000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 1000 mL over 12 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1000 mL12 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
500 mg of a drug is diluted in 500 mL and given by gravity through a set of 15 gtt/mL. The order is 20 mg per hour. Find the drip rate R in drops per minute.
500 mg/500 mL20 mg/h15 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 12 units/kg/h for a patient who weighs 76 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL12 units/kg/h76 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 500 mg in 250 mL. The order is 12.5 mcg/kg/min for a patient who weighs 62 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
500 mg/250 mL12.5 mcg/kg/min62 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 fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 150 mL/h. At 15:00, 250 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL250 mL infused150 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: no; gait: weak; mental status: overestimates or forgets limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 117 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?
MAP 65 mmHgSBP 117 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 80 mmHg (10.7 kPa). Use the rule that in acute respiratory acidosis HCO₃⁻ rises by 1 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
At sea level, a practice gas taken on 24% oxygen shows PaO₂ 75 mmHg (10.0 kPa) and PaCO₂ 54 mmHg (7.2 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
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
1atrial fibrillation
2junctional rhythm
3normal sinus rhythm
4sinus bradycardia
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
1idioventricular rhythm
2dual-chamber (AV) paced rhythm
3third-degree (complete) AV block
4sinus rhythm with wide QRS
3Solutions
1.Nursing fundamentals
Answer: A · Lift them off the mattress with a pillow under the calves
Why this is the answer
Heels have little padding and develop ulcers quickly. "Floating" them, with the support under the calves and the knee slightly bent, removes pressure from the heel.
Answer
A · Lift them off the mattress with a pillow under the calves
2.Nursing fundamentals
Answer: B · Let it bleed freely, wash with soap and running water, then report it urgently
Why this is the answer
First aid is to let the wound bleed freely without squeezing, wash it with soap and running water and cover it, without scrubbing or sucking. Reporting straight away allows a risk assessment and, if needed, post-exposure prophylaxis.
Answer
B · Let it bleed freely, wash with soap and running water, then report it urgently
3.Infection control & patient safety
Answer: B · Turn the patient on their side and protect them from injury without restraining
Why this is the answer
The nurse stays with the patient, turns them to the side to keep the airway clear, moves hard objects away and times the seizure. Objects in the mouth and restraint can cause injury.
Answer
B · Turn the patient on their side and protect them from injury without restraining
4.Infection control & patient safety
Answer: D · Contact the prescriber to clarify before giving anything
Why this is the answer
Illegible or unclear orders are clarified directly with the prescriber. The nurse never guesses, and a held dose is reported so treatment is not missed.
Answer
D · Contact the prescriber to clarify before giving anything
5.Prioritization & delegation
Answer: A · “I will soak my feet in hot water every evening.”
Why this is the answer
Neuropathy can stop the patient feeling heat, so hot soaks can cause burns, and long soaking dries the skin. Daily checks, careful drying and well-fitting shoes are correct.
Answer
A · “I will soak my feet in hot water every evening.”
6.Prioritization & delegation
Answer: A · A patient five days after a stroke who needs help with bathing and has stable vital signs
Why this is the answer
A stable patient who needs help with activities of daily living is suitable for routine care by an assistant. A new chest tube, symptomatic hypoglycemia and the first postoperative assessment need a licensed nurse.
Answer
A · A patient five days after a stroke who needs help with bathing and has stable vital signs
7.Clinical nursing
Answer: A · Thyroid function, the lungs and the skin's sensitivity to sunlight
Why this is the answer
Amiodarone can cause hypo- or hyperthyroidism, pulmonary fibrosis, liver problems and photosensitivity. Regular monitoring of thyroid and liver function is needed.
Answer
A · Thyroid function, the lungs and the skin's sensitivity to sunlight
8.Clinical nursing
Answer: C · Standard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
Why this is the answer
Standard SpO2 can appear normal despite severe tissue hypoxia. Carboxyhaemoglobin is measured on a blood gas, and high-concentration oxygen is given.
Answer
C · Standard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
9.Lab values & electrolytes
Answer: A · Report it at once so cultures and antibiotics start quickly
Why this is the answer
Neutropenic fever is a medical emergency, because infection can progress to sepsis rapidly without the usual signs of inflammation. Blood cultures are taken and broad-spectrum antibiotics are started promptly as prescribed.Checked against:Watch Out for Fever · CDC (2024); What You Need to Know: Neutropenia and Risk for Infection · CDC
Answer
A · Report it at once so cultures and antibiotics start quickly
10.Lab values & electrolytes
Answer: D · Look for a source of blood loss in the gut
Why this is the answer
Iron deficiency in an older man or a postmenopausal woman suggests chronic blood loss, often from the gastrointestinal tract, including colorectal cancer. Iron is started, but endoscopy or colonoscopy is needed to find the cause.
Answer
D · Look for a source of blood loss in the gut
11.Pharmacology
Answer: C · Blood drug levels and kidney function
Why this is the answer
Tacrolimus levels are kept in a target range to prevent rejection and toxicity. Kidney damage, hyperkalaemia, high glucose and tremor are adverse effects, and interacting drugs and grapefruit are avoided.
Answer
C · Blood drug levels and kidney function
12.Pharmacology
Answer: D · To prevent peripheral neuropathy
Why this is the answer
Isoniazid causes pyridoxine deficiency, which can lead to peripheral neuropathy. The risk is greater in slow acetylators, malnourished patients and people with diabetes or alcohol dependence.
Answer
D · To prevent peripheral neuropathy
13.Med-surg: cardiovascular & respiratory
Answer: A · No more than half the internal diameter of the tube
Why this is the answer
A catheter no larger than half the internal diameter of the tube lets air enter around it, reducing negative pressure in the lungs, atelectasis and hypoxaemia. Catheter size is often calculated from the tube size.
Answer
A · No more than half the internal diameter of the tube
14.Med-surg: cardiovascular & respiratory
Answer: C · The right main bronchus
Why this is the answer
Inhaled foreign bodies most often enter the right main bronchus and right lower lobe, because the right bronchus is wider, shorter and more vertical. Signs include a unilateral wheeze, reduced breath sounds and recurrent infection. Bronchoscopy is used for removal.
Answer
C · The right main bronchus
15.Med-surg: neuro, endocrine & renal
Answer: A · Nausea, diarrhoea and a slow heart rate
Why this is the answer
Donepezil is a cholinesterase inhibitor. Raised acetylcholine can cause nausea, vomiting, diarrhoea, vivid dreams and bradycardia, which can lead to dizziness or fainting.
Answer
A · Nausea, diarrhoea and a slow heart rate
16.Med-surg: neuro, endocrine & renal
Answer: A · Treat the low and report the pattern so the evening dose is reviewed
Why this is the answer
Nocturnal hypoglycaemia must be treated. A high morning glucose after a night-time low may reflect rebound (the Somogyi effect) or a separate cause; in either case the evening insulin regimen needs review. Giving extra insulin at night would make the hypoglycaemia worse.
Answer
A · Treat the low and report the pattern so the evening dose is reviewed
17.Med-surg: GI, perioperative & oncology
Answer: C · New diarrhoea or abdominal pain
Why this is the answer
Checkpoint inhibitors can cause immune-mediated colitis, pneumonitis, hepatitis, skin reactions and endocrine problems. Early reporting allows grading and treatment, often with corticosteroids.
Answer
C · New diarrhoea or abdominal pain
18.Med-surg: GI, perioperative & oncology
Answer: D · Pain may be undertreated; reassess and ask for a review of the plan
Why this is the answer
Clock-watching often reflects inadequate analgesia. The nurse reassesses pain and function, considers multimodal options, and asks the prescriber to review the plan rather than labelling the patient.
Answer
D · Pain may be undertreated; reassess and ask for a review of the plan
19.Maternity & obstetric nursing
Answer: B · 2 cm below the ischial spines
Why this is the answer
Station is measured in centimetres relative to the ischial spines. Negative numbers are above them, 0 is at their level and positive numbers are below them, towards the outlet.
Answer
B · 2 cm below the ischial spines
20.Maternity & obstetric nursing
Answer: A · Offer the parents time to see and hold their baby
Why this is the answer
Parents should be offered time with their baby, to name, hold and dress the baby if they wish, and keepsakes such as photographs, footprints or locks of hair. Their choices should be respected without pressure.
Answer
A · Offer the parents time to see and hold their baby
21.Pediatric nursing
Answer: B · Obesity with low physical activity
Why this is the answer
Obesity and inactivity are the main modifiable risk factors for type 2 diabetes in young people. Family history and ethnicity also raise risk but cannot be changed. Healthy eating and activity are the basis of prevention and treatment.
Answer
B · Obesity with low physical activity
22.Pediatric nursing
Answer: B · A life-threatening deterioration with exhaustion and very poor air movement
Why this is the answer
A "silent chest" and drowsiness mean that too little air is moving and the child is tiring. This is an emergency: call for help, give oxygen and emergency treatment as ordered.
Answer
B · A life-threatening deterioration with exhaustion and very poor air movement
23.Mental health nursing
Answer: D · It is a partial agonist at dopamine D2 receptors
Why this is the answer
As a partial agonist, aripiprazole lowers dopamine activity where it is high and supports it where it is low. It is less likely to raise prolactin or cause sedation, but akathisia is a common side effect.
Answer
D · It is a partial agonist at dopamine D2 receptors
24.Mental health nursing
Answer: B · Call for help, open the airway and support breathing, and give naloxone as prescribed or per protocol
Why this is the answer
Airway and breathing support come first, with naloxone given to reverse opioid effects. The patient is monitored closely because naloxone may wear off before the opioid.
Answer
B · Call for help, open the airway and support breathing, and give naloxone as prescribed or per protocol
25.Nursing math & unit conversions
Answer: 8:30 PM
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
20 − 12 = 8 → PM
Answer
8:30 PM
Answer
8:30 PM
26.Nursing math & unit conversions
Answer: V = 280 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
¾ cup = 0.75·240 = 180 mL
1 fl oz = 1·30 = 30 mL
4 tbsp = 4·15 = 60 mL
2 tsp = 2·5 = 10 mL
Add
V = 180 + 30 + 60 + 10 = 280 mL
Answer
V = 280 mL
27.Dosage calculations
Answer: D = 64.5 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).
Dose
D = 50·1.29 = 64.5 mg
Answer
D = 64.5 mg
28.Dosage calculations
Answer: V = 0.37 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 3700/10000 = 0.37 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.37 mL
29.IV infusion rates
Answer: R = 14 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
12·60 = 720 min
Drip rate
R = 1000·10/720 = 13.89 ≈ 14 gtt/min
Answer
R = 14 gtt/min
At the bedside you round to the nearest whole drop: 14 gtt/min.
30.IV infusion rates
Answer: R = 5 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
500/500 = 1 mg/mL
Volume per hour
20/1 = 20 mL/h
Drip rate
R = 20·15/60 = 5 gtt/min
Answer
R = 5 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 22.8 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
12·76 = 912 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 912/40 = 22.8 mL/h
Answer
R = 22.8 mL/h
32.Pediatric & critical-care dosing
Answer: R = 23.3 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
500 mg = 500 000 mcg
500 000/250 = 2000 mcg/mL
Dose per minute and per hour
12.5·62 = 775 mcg/min
775·60 = 46500 mcg/h
Pump rate
R = 46500/2000 = 23.25 ≈ 23.3 mL/h
Answer
R = 23.3 mL/h
33.IV fluids & fluid balance
Answer: B = 160 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.
Total intake
oral: 200 + 200 + 240 = 640 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 1·100 = 100 mL
total intake = 1460 mL
Total output
400 + 350 + 300 + 100 + 150 = 1300 mL
Balance
B = 1460 − 1300 = 160 mL
Answer
B = 160 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 1.7 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
500 − 250 = 250 mL
Time
t = 250/150 = 1.667 ≈ 1.7 h
Answer
t = 1.7 h
That is about 1 h 40 min, so the bag runs out at about 16:40.
35.Clinical assessment scores
Answer: MFS = 65
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: no → 0
gait: weak → 10
mental status: overestimates or forgets limits → 15
Add
Morse total = 25 + 15 + 0 + 0 + 10 + 15 = 65
Answer
MFS = 65
36.Clinical assessment scores
Answer: DBP = 39 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·65 − 117)/2 = 78/2 = 39 mmHg
Answer
DBP = 39 mmHg
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 28 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
|80 − 40| = 40 mmHg → 4 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·4 = 28 mmol/L
Answer
HCO₃⁻ = 28 mmol/L
38.Arterial blood gas interpretation
Answer: A–a gradient = 28.62 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
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 = 36 small boxes, 1500 ÷ 36 ≈ 42 per minute.
2. Rhythm: regular, every R–R is 1.44 s.
3. P waves: inverted, just after each QRS.
4. PR interval: not measurable.
5. QRS: 0.10 s, narrow (below 0.12 s).
Interpretation
junctional rhythm
Answer
junctional rhythm
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 = 22 small boxes, 1500 ÷ 22 ≈ 68 per minute.
2. Rhythm: regular, every R–R is 0.88 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.20 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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