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
While wearing sterile gloves, where should the nurse keep their hands?
AAbove waist level and in sight
BFolded under the armpits to keep warm
CResting on the edge of the sterile field
DBehind the back when not in use
2.Nursing fundamentalsHard
A patient on a ward suddenly becomes unresponsive and is not breathing normally. What is the first action?
AMeasure the blood pressure
BLie the patient on the side and observe
CCall for help and start CPR
DCheck the blood glucose before anything else
3.Infection control & patient safetyMedium
Which information must be documented when a patient is restrained?
AOnly whether the family agreed to the restraint
BOnly the time the restraint was put on and the time it was taken off
CThe reason, alternatives tried, type of restraint, times and regular assessments
DOnly the name of the nurse who applied it and the unit where it happened
4.Infection control & patient safetyHard
A nurse who has a cold sore (herpes labialis) is assigned to the newborn nursery. What is most appropriate?
ATell no one, and cover the lesion with makeup during shifts
BWork as usual, since cold sores are very common
CWear gloves and carry on as usual
DInform the manager, who may reassign the nurse for now
5.Prioritization & delegationMedium
A nurse teaches a patient about levothyroxine. Which statement shows a need for further teaching?
A“I will take it at breakfast with my calcium tablet.”
B“I will keep taking it even when I feel well.”
C“I will take it at the same time each morning.”
D“I will take it on an empty stomach with a glass of water.”
6.Prioritization & delegationHard
Four patients arrive at the emergency department together. Who should be seen first?
AA teenager with a cut on the arm whose bleeding is controlled
BA 2-year-old who is drooling, sitting forward and has stridor
CAn adult with a deformed ankle and a normal pulse in the foot
DAn adult with a migraine and a blood pressure of 150/90 mmHg
7.Clinical nursingMedium
Why are patients with atrial fibrillation often given anticoagulants?
ATo slow the heart rate directly and prevent palpitations
BTo lower the blood pressure
CTo reduce the risk of stroke from clots in the atria
DTo convert the rhythm back to normal
8.Clinical nursingHard
Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?
AIV syringes cannot hold liquid medicines
BEnteral syringes measure doses less accurately
CEnteral syringes keep the medicine sterile
DTo prevent accidental intravenous administration
9.Lab values & electrolytesMedium
A patient with hyperkalemia received IV regular insulin with dextrose. Which result must the nurse monitor closely over the next hours?
ASerum calcium, because it falls sharply
BBlood glucose, because hypoglycemia can occur
CHemoglobin, because insulin causes red cell loss
DSerum sodium, because it rises quickly
10.Lab values & electrolytesHard
A patient took a large overdose of acetaminophen (paracetamol) 24 hours ago. Which laboratory changes are most expected?
AA low ALT and AST and a low INR
BA high troponin with a normal ALT
CA very high ALT and AST and a rising INR
DA low white count with normal liver tests
11.PharmacologyMedium
A patient must mix regular (soluble) insulin and NPH (isophane) insulin in one syringe. What is the correct order?
ADraw them up in separate syringes, then mix them in a cup
BShake both vials hard, then draw them up in any order
CDraw up the cloudy NPH insulin first, then the clear regular insulin
DDraw up the clear regular insulin first, then the cloudy NPH insulin
12.PharmacologyHard
A nurse gave a patient ten times the prescribed dose of hydromorphone. The patient is currently alert. What is the most appropriate sequence of actions?
AMonitor closely, have naloxone ready, inform the prescriber and report
BSay nothing because the patient is alert
CChange the chart so that it shows the correct dose, and continue to monitor
DGive another dose later to balance it out
13.Med-surg: cardiovascular & respiratoryMedium
A patient is starting long-term amiodarone. Which teaching and monitoring are most important?
AEat extra salt and stop the drug as soon as the pulse is regular
BExpect orange urine and no need for blood tests
CProtect skin from sunlight and have thyroid, liver and lung checks
DAvoid dairy products and have the INR checked once at the start
14.Med-surg: cardiovascular & respiratoryHard
A patient has new chest pain at rest. The ECG shows ST depression, but serial troponins remain normal. Which diagnosis fits best?
AST-elevation myocardial infarction
BUnstable angina
CStable angina
DNon-ST-elevation myocardial infarction
15.Med-surg: neuro, endocrine & renalMedium
Why is propranolol given to a patient with hyperthyroidism?
ATo ease tremor and palpitations while other treatment starts
BTo replace the hormone lost from the thyroid gland
CTo destroy overactive thyroid tissue over a few weeks
DTo stop the thyroid gland from making any more hormones
16.Med-surg: neuro, endocrine & renalHard
A patient with raised intracranial pressure needs endotracheal suctioning. Which approach is most appropriate?
ASuction every 15 minutes as a routine, even without secretions
BPre-oxygenate, keep each pass short and limit the number of passes
CLie the patient flat with the head turned during suctioning
DSuction for at least 30 seconds to clear all secretions at once
17.Med-surg: GI, perioperative & oncologyMedium
A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?
AAvoid all fruit and vegetables for the rest of their life
BDrink as little fluid as possible to reduce output
CEat a normal, balanced diet and introduce foods gradually
DEat only liquids until the stoma is removed
18.Med-surg: GI, perioperative & oncologyHard
A dying patient has noisy, rattling breathing. The patient seems unaware, but the family is distressed. What is the best nursing approach?
AAsk the family to leave the room
BGive large volumes of IV fluid to loosen and thin the secretions
CReposition, explain the cause and give prescribed drugs if needed
DPerform deep suction every hour
19.Maternity & obstetric nursingMedium
During the hip examination, the nurse hears a "clunk" as the newborn's hip is abducted. What does this suggest?
AA fractured femur from the birth
BDevelopmental dysplasia of the hip
CClubfoot affecting the same side
DA normal finding in all newborns
20.Maternity & obstetric nursingHard
Just after her membranes rupture in labour, a woman suddenly becomes very breathless, cyanosed and hypotensive. Which condition should be suspected?
AA panic attack
BNormal response to a strong contraction
CSupine hypotension
DAmniotic fluid embolism
21.Pediatric nursingMedium
Which instruction about a child's new plaster cast is correct?
AKeep the limb raised and report increasing pain, numbness or pale or blue fingers
BPush a knitting needle inside the cast to scratch an itch
CKeep the cast covered with a plastic bag at all times while it dries, to keep it clean
DLet the child walk on a leg cast as soon as it is applied
22.Pediatric nursingHard
An infant with heart failure is breathing fast and working hard. Which position helps most?
AFlat on the back with the legs raised
BProne with the head turned to the side
CSemi-upright, with the head and chest raised
DLying flat on the left side only
23.Mental health nursingMedium
A woman calls the emergency department after a sexual assault an hour ago. What advice helps to preserve forensic evidence?
AWait a few days at home until she feels ready to talk before seeking any medical care or forensic examination
BPut all clothing in a sealed plastic bag
CAvoid showering or changing clothes, and bring any clothing already removed in a paper bag
DShower and wash her clothes before coming in, so she feels cleaner
24.Mental health nursingHard
A patient with PTSD suddenly appears terrified, staring and breathing quickly, and says she is "back there". What should the nurse do first?
ALeave the room so she can calm down alone
BAsk her to describe every detail of the trauma straight away so that she can process the memory
CTouch her suddenly from behind to get her attention
DSpeak calmly, use her name and use grounding techniques to bring her attention to the present
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.81547 mL. The rule in this exercise is that volumes below 1 mL are rounded to the nearest hundredth of a mL. What value x do you record?
0.81547 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 12 mcg/min. Express this dose rate D in mg/h.
12 mcg/min1 h = 60 min1 mg = 1000 mcg
D = mg/h
27.Dosage calculationsMedium
A vial contains 2 g of powder. The label says: add 9.2 mL of water for injection to give a total volume of 10 mL. The prescription is 240 mg. What volume V of the reconstituted solution do you give?
2 g+ 9.2 mL → 10 mL240 mg
V = mL
28.Dosage calculationsHard
A patient weighs 134.2 lb. The prescription is 5 mg/kg as a single dose, and the stock contains 200 mg in 5 mL. Using 1 kg = 2.2 lb, what volume V do you give? Round to one decimal place.
134.2 lb5 mg/kg200 mg/5 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
500 mL was ordered over 8 hours. After 2 hours you find that 470 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
500 mL / 8 hafter 2 h: 470 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 500 mg of a drug in 50 mL and runs at 15 mL/h. How many milligrams per hour D does the patient receive?
500 mg/50 mL15 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 80 units/kg for a patient who weighs 79 kg. The vial contains 5 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg79 kg5 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 2.5 mcg/kg/min for a patient who weighs 74 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL2.5 mcg/kg/min74 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 10:30 and runs by pump at 80 mL/h. How many mL V are left in the bag at 17:30?
1000 mL80 mL/h10:30 → 17:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 13, with E4 and V4. What motor score M was recorded, and which response does it describe? Give the number.
GCS 13E4V4
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 106 kg and is 178 cm tall. Calculate the BMI and click the WHO weight category.
106 kg178 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 138 mmol/L, glucose 6.8 mmol/L and urea 6.2 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 138 mmol/Lglucose 6.8 mmol/Lurea 6.2 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.20, PaCO₂ 48 mmHg (6.4 kPa), HCO₃⁻ 18 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.20PaCO₂ 48 mmHg (6.4 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
1atrial flutter, 2:1 conduction
2ventricular tachycardia
3accelerated junctional rhythm
4supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. 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
1second-degree AV block type II
2third-degree (complete) AV block
3first-degree AV block
4second-degree AV block type I (Wenckebach)
3Solutions
1.Nursing fundamentals
Answer: A · Above waist level and in sight
Why this is the answer
Sterile hands are kept in front of the body, above the waist and within sight, so accidental contamination is noticed. The edge of the field is not sterile.
Answer
A · Above waist level and in sight
2.Nursing fundamentals
Answer: C · Call for help and start CPR
Why this is the answer
Unresponsive and not breathing normally means cardiac arrest: call for help (arrest team, defibrillator) and start chest compressions immediately.
Answer
C · Call for help and start CPR
3.Infection control & patient safety
Answer: C · The reason, alternatives tried, type of restraint, times and regular assessments
Why this is the answer
Restraint documentation includes the behavior that made it necessary, less restrictive measures tried, the order, the type used, the times applied and released, and ongoing checks of circulation, skin, needs and mental state.
Answer
C · The reason, alternatives tried, type of restraint, times and regular assessments
4.Infection control & patient safety
Answer: D · Inform the manager, who may reassign the nurse for now
Why this is the answer
Herpes simplex can cause severe infection in newborns. Staff with active lesions inform their manager and follow occupational health advice, which often means avoiding contact with newborns and other high-risk patients until the lesion has healed.
Answer
D · Inform the manager, who may reassign the nurse for now
5.Prioritization & delegation
Answer: A · “I will take it at breakfast with my calcium tablet.”
Why this is the answer
Levothyroxine is best absorbed on an empty stomach and is separated from calcium and iron by several hours. It is usually lifelong, so it is not stopped when the patient feels better.
Answer
A · “I will take it at breakfast with my calcium tablet.”
6.Prioritization & delegation
Answer: B · A 2-year-old who is drooling, sitting forward and has stridor
Why this is the answer
Drooling, a forward-leaning (tripod) position and stridor suggest a severe upper airway obstruction, such as epiglottitis, which can become complete quickly. The child should be kept calm and the throat not examined until airway experts are present.
Answer
B · A 2-year-old who is drooling, sitting forward and has stridor
7.Clinical nursing
Answer: C · To reduce the risk of stroke from clots in the atria
Why this is the answer
In AF the atria do not contract effectively, so blood can pool and clot, especially in the left atrial appendage. A clot can travel to the brain, so anticoagulation reduces stroke risk.
Answer
C · To reduce the risk of stroke from clots in the atria
8.Clinical nursing
Answer: D · To prevent accidental intravenous administration
Why this is the answer
Giving an oral or enteral medicine intravenously can be fatal. Enteral syringes with non-IV connectors, such as ENFit, make this wrong-route error much less likely.
Answer
D · To prevent accidental intravenous administration
9.Lab values & electrolytes
Answer: B · Blood glucose, because hypoglycemia can occur
Why this is the answer
Insulin shifts potassium into cells but also lowers glucose, and hypoglycemia can occur hours later, especially in kidney failure. Glucose is checked frequently, and potassium is rechecked, as the effect lasts only a few hours.Checked against:High potassium level · MedlinePlus (NIH) (2025)
Answer
B · Blood glucose, because hypoglycemia can occur
10.Lab values & electrolytes
Answer: C · A very high ALT and AST and a rising INR
Why this is the answer
A toxic dose damages liver cells, so ALT and AST rise steeply, and liver failure raises the INR. Acetylcysteine is the antidote and works best when given early.Checked against:Acetaminophen Toxicity · StatPearls (NCBI Bookshelf) (2026)
Answer
C · A very high ALT and AST and a rising INR
11.Pharmacology
Answer: D · Draw up the clear regular insulin first, then the cloudy NPH insulin
Why this is the answer
Drawing up regular insulin first prevents NPH from contaminating the regular insulin vial. NPH is gently rolled, not shaken, to mix it.
Answer
D · Draw up the clear regular insulin first, then the cloudy NPH insulin
12.Pharmacology
Answer: A · Monitor closely, have naloxone ready, inform the prescriber and report
Why this is the answer
The patient may become sedated and develop respiratory depression later, so close monitoring and a ready antidote are needed. The prescriber is informed, the patient is told honestly, and the error is reported to improve the system.
Answer
A · Monitor closely, have naloxone ready, inform the prescriber and report
13.Med-surg: cardiovascular & respiratory
Answer: C · Protect skin from sunlight and have thyroid, liver and lung checks
Why this is the answer
Amiodarone causes photosensitivity, thyroid dysfunction (it contains iodine), liver toxicity, pulmonary fibrosis and corneal deposits. Patients use high-factor sunscreen and have regular thyroid and liver tests and reviews for cough or breathlessness. It also interacts with warfarin and digoxin.
Answer
C · Protect skin from sunlight and have thyroid, liver and lung checks
14.Med-surg: cardiovascular & respiratory
Answer: B · Unstable angina
Why this is the answer
Unstable angina is new, worsening or rest angina without a troponin rise. It is an acute coronary syndrome and is managed urgently because it can progress to infarction. Stable angina is predictable and exertional. NSTEMI has a rising troponin.
Answer
B · Unstable angina
15.Med-surg: neuro, endocrine & renal
Answer: A · To ease tremor and palpitations while other treatment starts
Why this is the answer
A beta-blocker quickly controls adrenergic symptoms such as tachycardia, tremor and anxiety. It does not lower hormone production, so a thionamide, radioactive iodine or surgery is still needed.
Answer
A · To ease tremor and palpitations while other treatment starts
16.Med-surg: neuro, endocrine & renal
Answer: B · Pre-oxygenate, keep each pass short and limit the number of passes
Why this is the answer
Suctioning raises ICP through coughing, hypoxia and hypercapnia. It is done only when needed, with pre-oxygenation, passes of no more than about 10–15 seconds, few passes and the head kept elevated and midline. Sedation or lidocaine may be used in some units.
Answer
B · Pre-oxygenate, keep each pass short and limit the number of passes
17.Med-surg: GI, perioperative & oncology
Answer: C · Eat a normal, balanced diet and introduce foods gradually
Why this is the answer
People with a colostomy can usually eat a normal diet. Foods are reintroduced gradually to see how each one affects gas, odour and output, and regular meals and fluids help.
Answer
C · Eat a normal, balanced diet and introduce foods gradually
18.Med-surg: GI, perioperative & oncology
Answer: C · Reposition, explain the cause and give prescribed drugs if needed
Why this is the answer
Noisy respiratory secretions near death come from secretions in the throat that the patient cannot clear. Repositioning, explanation and anticholinergic drugs may help; deep suction is usually distressing and ineffective.
Answer
C · Reposition, explain the cause and give prescribed drugs if needed
19.Maternity & obstetric nursing
Answer: B · Developmental dysplasia of the hip
Why this is the answer
A clunk with the Ortolani or Barlow manoeuvre suggests a dislocated or dislocatable hip. Asymmetrical skin folds and limited abduction are other signs. Early ultrasound and treatment give good results.
Answer
B · Developmental dysplasia of the hip
20.Maternity & obstetric nursing
Answer: D · Amniotic fluid embolism
Why this is the answer
Amniotic fluid embolism causes sudden breathlessness, hypoxia, hypotension and often bleeding from coagulopathy. It is an emergency: call the emergency team and start resuscitation as needed.
Answer
D · Amniotic fluid embolism
21.Pediatric nursing
Answer: A · Keep the limb raised and report increasing pain, numbness or pale or blue fingers
Why this is the answer
Elevation reduces swelling, and families must report signs of neurovascular compromise (pain, pallor, numbness, tingling, coolness or inability to move fingers or toes). Nothing should be pushed into the cast, and a wet cast needs air to dry.
Answer
A · Keep the limb raised and report increasing pain, numbness or pale or blue fingers
22.Pediatric nursing
Answer: C · Semi-upright, with the head and chest raised
Why this is the answer
A semi-upright position lowers the pressure of abdominal organs on the diaphragm and eases breathing. Raising the legs would increase venous return and may worsen pulmonary congestion.
Answer
C · Semi-upright, with the head and chest raised
23.Mental health nursing
Answer: C · Avoid showering or changing clothes, and bring any clothing already removed in a paper bag
Why this is the answer
Not washing, changing or eating where possible helps keep evidence. Paper bags are used because plastic traps moisture and can degrade biological evidence. Her medical needs and choices remain the priority.
Answer
C · Avoid showering or changing clothes, and bring any clothing already removed in a paper bag
24.Mental health nursing
Answer: D · Speak calmly, use her name and use grounding techniques to bring her attention to the present
Why this is the answer
During a flashback, grounding (orienting to the present, using the senses, calm reassurance) helps the patient regain contact with reality. Detailed trauma work belongs in planned therapy, and sudden touch can be frightening.
Answer
D · Speak calmly, use her name and use grounding techniques to bring her attention to the present
25.Nursing math & unit conversions
Answer: x = 0.82 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the hundredths place
0.81547 → 1
Only the next digit decides
0.81547 → 5
5 is 5 or more, so round 1 up.
The digits after it (47) are ignored: round once, never step by step.
Round
x = 0.82 mL
Answer
x = 0.82 mL
26.Nursing math & unit conversions
Answer: D = 0.72 mg/h
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 12 mcg/min × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 12·60/1000 = 0.72 mg/h
Answer
D = 0.72 mg/h
27.Dosage calculations
Answer: V = 1.2 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration after mixing
2000 mg/10 mL = 200 mg/mL
Volume
V = 240/200 = 1.2 mL
Answer
V = 1.2 mL
28.Dosage calculations
Answer: V = 7.6 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.
Weight in kg
134.2/2.2 = 61 kg
Dose
5·61 = 305 mg
Volume
V = (305/200)·5 = 7.625 ≈ 7.6 mL
Answer
V = 7.6 mL
29.IV infusion rates
Answer: R = 78.33 mL/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
500/8 = 62.5 mL/h
New rate
R = 470/6 = 78.33 mL/h
Answer
R = 78.33 mL/h
This is more than a 25% increase: most hospitals require you to contact the prescriber instead of catching up, and to assess the patient for fluid overload.
30.IV infusion rates
Answer: D = 150 mg/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Concentration
500/50 = 10 mg/mL
Dose rate
D = 10·15 = 150 mg/h
Answer
D = 150 mg/h
31.Pediatric & critical-care dosing
Answer: V = 1.3 mL
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 needed
80·79 = 6 320 units
Volume
V = 6320/5000 = 1.264 ≈ 1.3 mL
Answer
V = 1.3 mL
32.Pediatric & critical-care dosing
Answer: R = 11.1 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
250 mg = 250 000 mcg
250 000/250 = 1000 mcg/mL
Dose per minute and per hour
2.5·74 = 185 mcg/min
185·60 = 11100 mcg/h
Pump rate
R = 11100/1000 = 11.1 mL/h
Answer
R = 11.1 mL/h
33.IV fluids & fluid balance
Answer: B = 395 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: 250 + 120 + 180 = 550 mL
ice chips: 240/2 = 120 mL
IV infusion: 75·12 = 900 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1770 mL
Total output
300 + 450 + 150 + 425 + 50 = 1375 mL
Balance
B = 1770 − 1375 = 395 mL
Answer
B = 395 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 440 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
10:30 → 17:30 = 7 h
Volume infused
80·7 = 560 mL
Volume left
V = 1000 − 560 = 440 mL
Answer
V = 440 mL
35.Clinical assessment scores
Answer: M = 5
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 = 13 − 4 − 4 = 5
M5: moves a hand to the site of pressure (localises)
Answer
M = 5
36.Clinical assessment scores
Answer: obesity class I
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 = 106/1.78² = 33.46
Category
obesity class I
Answer
obesity class I
37.Arterial blood gas interpretation
Answer: Osm = 289 mOsm/kg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Calculated osmolality
Osm = 2·138 + 6.8 + 6.2 = 289 ≈ 289 mOsm/kg
Answer
Osm = 289 mOsm/kg
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: 48 mmHg → added respiratory acidosis
Answer
added respiratory acidosis
39.ECG rhythm strip interpretation
Answer: supraventricular tachycardia (SVT)
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. Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Five steps
1. Rate: R–R = 10 small boxes, 1500 ÷ 10 ≈ 150 per minute.
2. Rhythm: regular, every R–R is 0.40 s.
3. P waves: none visible; at this rate they are hidden in the QRS complexes or the T waves.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s), so the rhythm starts above the ventricles.
Interpretation
supraventricular tachycardia (SVT)
Answer
supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretation
Answer: second-degree AV block type II
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Five steps
1. Rate: 6 QRS complexes in 6 s, × 10 = 60 per minute.
2. Rhythm: the P waves are regular; R–R is regular except for a long pause where a QRS is missing.
3. P waves: upright and regular (P–P 0.76 s, 79 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: constant at 0.24 s in the conducted beats.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
second-degree AV block type II
Answer
second-degree AV block type II
Type II and third-degree blocks are the ones that can suddenly progress, so textbooks rank them as more serious than type I.
This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.