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 ear be positioned when taking a tympanic temperature in an adult?
AGently pull the outer ear up and back
BGently pull the outer ear down and back
CPush the outer ear forward against the cheek
DLeave the ear alone and insert the probe deeply
2.Nursing fundamentalsHard
A patient opens their eyes only to pain, makes incomprehensible sounds and withdraws from a painful stimulus. What is the Glasgow Coma Scale score?
A11
B8
C6
D9
3.Infection control & patient safetyMedium
A peripheral IV site is red, warm and tender along the vein. What should the nurse do?
AApply a warm pack and keep using the same site
BRemove the catheter and insert a new one at another site if still needed
CIncrease the infusion rate to finish the bag sooner
DFlush the catheter harder to clear the vein and keep using the same site
4.Infection control & patient safetyHard
A nurse has weeping dermatitis on both hands. What is the most appropriate action?
AContinue care as usual and wear one pair of gloves
BAvoid direct patient care and handling of equipment until it heals, and see occupational health
CCover the lesions with a waterproof bandage and keep working with patients as usual
DUse extra alcohol hand rub on the lesions
5.Prioritization & delegationMedium
Before giving a medication to a child, which check is especially important?
AThat the medicine cup is the child’s favorite color
BThat the dose is correct for the child’s weight
CThat the child likes the taste of the drug
DThat the parent agrees with the time it is given
6.Prioritization & delegationHard
An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?
AGiving a high-protein meal to support healing
BLarge-volume IV fluids with close monitoring of urine output
CApplying antibiotic cream to all the burns before anything else
DStarting physiotherapy to prevent contractures straight away
7.Clinical nursingMedium
Which instruction is correct for taking weekly alendronic acid (alendronate)?
AChew the tablet with breakfast and a cup of milky tea
BTake it with a glass of milk at bedtime and then lie down straight away
CTake it with plain water on an empty stomach and stay upright for 30 minutes
DTake it with an antacid to protect the stomach
8.Clinical nursingHard
An older patient's blood pressure is 142/80 mmHg lying and 116/72 mmHg after standing for three minutes, and they feel dizzy. What does this show?
AHypertensive emergency
BNormal blood pressure variation
CWhite coat hypertension
DPostural hypotension
9.Lab values & electrolytesMedium
A patient with type 2 diabetes starts prednisone each morning. When is the glucose most likely to be highest?
AAt midnight only
BThe glucose will not change
CIn the afternoon and evening
DIn the early morning, before the dose
10.Lab values & electrolytesHard
A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?
ACertain sepsis that needs antibiotics started without delay
BA laboratory error, because steroids always lower the white count
CA new leukemia that is confirmed by this result alone
DA steroid effect that moves neutrophils into the circulating blood
11.PharmacologyMedium
A child weighing 20 kg is prescribed a drug at 15 mg/kg per dose. What is the dose?
A150 mg
B35 mg
C3000 mg
D300 mg
12.PharmacologyHard
A patient with severe chronic hyponatraemia receives hypertonic saline. Why is the rate of correction strictly limited?
ARaising sodium too fast can cause osmotic demyelination in the brain
BRaising sodium too fast causes severe hypokalaemia and cardiac arrest
CFast correction causes immediate kidney failure
DHypertonic saline is toxic to the liver at high rates
13.Med-surg: cardiovascular & respiratoryMedium
Why must intravenous potassium chloride never be given as a rapid push or undiluted?
AIt turns into solid crystals inside the vein and blocks it
BIt immediately lowers the blood glucose to dangerous levels
CA sudden high potassium level can cause cardiac arrest
DIt works only when given by mouth
14.Med-surg: cardiovascular & respiratoryHard
A patient on spironolactone and an ACE inhibitor has a potassium of 6.8 mmol/L (6.8 mEq/L) with peaked T waves. What is usually given first to protect the heart?
AOral potassium supplements
BAn IV furosemide bolus as the only treatment
CIntravenous calcium gluconate or chloride
DA dose of digoxin
15.Med-surg: neuro, endocrine & renalMedium
Why do patients with CKD often take phosphate binders with meals?
AThey bind food phosphate that the kidneys cannot excrete
BThey increase the absorption of phosphate from food in the gut
CThey lower blood potassium by binding it in the gut
DThey replace the missing hormone erythropoietin
16.Med-surg: neuro, endocrine & renalHard
A patient with nephrotic syndrome suddenly has loin pain, blood in the urine and a rise in creatinine. What is a likely cause?
ANormal fluctuation in the disease
BA simple bladder infection
CToo much dietary protein
DRenal vein thrombosis
17.Med-surg: GI, perioperative & oncologyMedium
Which practice is correct when giving parenteral nutrition through a central line?
AUse a dedicated lumen and strict aseptic technique
BLet the bag hang at room temperature for several days
CDisconnect and reconnect the line without cleaning the hub
DGive other IV drugs through the same lumen to save time
18.Med-surg: GI, perioperative & oncologyHard
A patient with suspected appendicitis says the pain suddenly eased, but an hour later has a temperature of 38.9 °C, a rigid abdomen and a pulse of 118/min. What does this suggest?
AThe appendicitis has settled by itself
BA side effect of the analgesia given
CPerforation with peritonitis
DSimple constipation that needs a laxative
19.Maternity & obstetric nursingMedium
Which findings are typical of placental abruption?
APainless bright red bleeding with a soft, relaxed, non-tender uterus
BAbdominal pain, a firm or rigid uterus and dark red bleeding
CItching of the palms and soles
DLeaking clear fluid without contractions
20.Maternity & obstetric nursingHard
The triage nurse receives four phone calls from pregnant women. Who should be told to come in immediately?
AAt 30 weeks with heartburn after large meals
BAt 12 weeks with mild nausea in the mornings
CAt 36 weeks with constant pain and a hard uterus
DAt 25 weeks with mild backache after standing
21.Pediatric nursingMedium
Which drink is best for a child with mild dehydration from gastroenteritis?
ACola or other fizzy drinks
BOral rehydration solution
CUndiluted apple juice
DSports drinks
22.Pediatric nursingHard
A 6-year-old with sickle cell disease has a temperature of 39.0 °C. Why is this treated as urgent?
AFever is the normal start of every pain crisis
BIt is not urgent; fever is common in all children
CChildren with sickle cell disease have reduced spleen function and are at high risk of serious bacterial infection
DFever means a sickling crisis has started, so the child needs a blood transfusion straight away to replace the damaged cells
23.Mental health nursingMedium
Which statement about buspirone for anxiety is correct?
AIt takes weeks to work and is not useful as an as-needed drug
BIt is highly addictive
CIt must be taken with alcohol
DIt works within minutes during a panic attack, like a benzodiazepine
24.Mental health nursingHard
A nurse realises she has given a patient another patient's olanzapine dose. What should she do first?
ASay nothing, because one dose will not cause harm
BAssess the patient, including his vital signs and level of sedation
CGive the patient his own prescribed medicine as well, to stay on schedule
DFill in an incident report before checking the patient
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A drip-rate calculation gives 122.307 gtt/min. The rule in this exercise is that drip rates are rounded to the nearest whole drop. What value x do you record?
122.307 gtt/min
x = gtt/min
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A haemoglobin result is 84 g/L. Express it in g/dL Hb.
84 g/L1 L = 10 dL
Hb = g/dL
27.Dosage calculationsMedium
A patient weighs 30 kg and is prescribed 20 mg/kg as a single dose. Find the dose D in mg.
30 kg20 mg/kg
D = mg
28.Dosage calculationsHard
The prescription is 280 units of a drug that comes as 1000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
280 units1000 units/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 20 gtt/min through a set of 20 gtt/mL. How many millilitres V does the patient receive in 2 hours?
20 gtt/min20 gtt/mL2 h
V = mL
30.IV infusion ratesHard
1000 mL was ordered over 10 hours. After 6 hours you find that 500 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1000 mL / 10 hafter 6 h: 500 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 100 mL. The order is 3 units/h. Find the pump rate R in mL/h. Round to one decimal place.
100 units/100 mL3 units/h
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 67 kg has an order for norepinephrine at 8 mcg/min. The bag contains 4 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
4 mg/250 mL8 mcg/min67 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 8-hour shift. The patient weighs 85 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 150 mL/h. At 10:00, 200 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL200 mL infused150 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 16/min, SpO₂ 96% on room air, blood pressure 84/50 mmHg, pulse 70/min, alert, temperature 38.8 °C. What is the NEWS2 total score?
RR 16SpO₂ 96%airSBP 84HR 70AT 38.8 °C
NEWS2 =
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 111 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 111 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 72 mmHg (9.6 kPa). Use the rule that in chronic respiratory acidosis HCO₃⁻ rises by 3.5 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 35% oxygen shows PaO₂ 61 mmHg (8.1 kPa) and PaCO₂ 37 mmHg (4.9 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Bazett’s formula QTc = QT/√RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. The QRS complexes are regular: find the ventricular rate in beats per minute (1500 method, whole number).
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ventricular rate = bpm
3Solutions
1.Nursing fundamentals
Answer: A · Gently pull the outer ear up and back
Why this is the answer
Pulling the pinna up and back straightens the adult ear canal so the probe points at the eardrum. In young children the pinna is pulled down and back instead.
Answer
A · Gently pull the outer ear up and back
2.Nursing fundamentals
Answer: B · 8
Why this is the answer
Eyes to pain score 2, incomprehensible sounds score 2 and withdrawal from pain scores 4, giving 8. A GCS of 8 or less suggests the patient may not be able to protect their airway.
Answer
B · 8
3.Infection control & patient safety
Answer: B · Remove the catheter and insert a new one at another site if still needed
Why this is the answer
Redness, warmth and tenderness along the vein indicate phlebitis, which can lead to infection. The catheter is removed and, if IV access is still needed, a new one is placed at a different site.
Answer
B · Remove the catheter and insert a new one at another site if still needed
4.Infection control & patient safety
Answer: B · Avoid direct patient care and handling of equipment until it heals, and see occupational health
Why this is the answer
Weeping skin lesions increase the risk of passing organisms to patients and of the nurse picking up bloodborne pathogens. The nurse should avoid direct patient contact and handling of patient equipment until the condition is assessed and resolved.
Answer
B · Avoid direct patient care and handling of equipment until it heals, and see occupational health
5.Prioritization & delegation
Answer: B · That the dose is correct for the child’s weight
Why this is the answer
Pediatric doses are usually calculated by weight, and errors can cause serious harm. The nurse checks the dose against the child’s weight and the safe range before giving it.
Answer
B · That the dose is correct for the child’s weight
6.Prioritization & delegation
Answer: B · Large-volume IV fluids with close monitoring of urine output
Why this is the answer
Once the airway is secure, the early priority in major burns is fluid resuscitation to prevent burn shock. Urine output is a key guide to whether enough fluid is being given.
Answer
B · Large-volume IV fluids with close monitoring of urine output
7.Clinical nursing
Answer: C · Take it with plain water on an empty stomach and stay upright for 30 minutes
Why this is the answer
Alendronic acid must be taken with plain water before food, and the patient must stay upright to reduce oesophageal irritation. Food, milk and antacids reduce absorption.
Answer
C · Take it with plain water on an empty stomach and stay upright for 30 minutes
8.Clinical nursing
Answer: D · Postural hypotension
Why this is the answer
A fall in systolic pressure of 20 mmHg or more (here 26 mmHg) on standing, especially with symptoms, indicates postural hypotension. Causes include medicines, dehydration and autonomic problems.
Answer
D · Postural hypotension
9.Lab values & electrolytes
Answer: C · In the afternoon and evening
Why this is the answer
A morning dose of prednisone raises glucose mainly in the afternoon and evening, with a smaller effect overnight. Glucose monitoring and insulin plans often target these times, and doses are adjusted when the steroid is tapered.Checked against:Blood Glucose Test · MedlinePlus (NIH) (2024)
Answer
C · In the afternoon and evening
10.Lab values & electrolytes
Answer: D · A steroid effect that moves neutrophils into the circulating blood
Why this is the answer
Corticosteroids raise the neutrophil count by releasing marginated neutrophils and slowing their exit from the blood, usually without a left shift. The nurse still assesses carefully, because steroids can also hide the usual signs of infection.
Answer
D · A steroid effect that moves neutrophils into the circulating blood
11.Pharmacology
Answer: D · 300 mg
Why this is the answer
20 kg × 15 mg/kg = 300 mg. The result is also checked against the safe dose range and the adult maximum.
Answer
D · 300 mg
12.Pharmacology
Answer: A · Raising sodium too fast can cause osmotic demyelination in the brain
Why this is the answer
In chronic hyponatraemia the brain adapts to low osmolality. Correcting sodium too rapidly shrinks brain cells and can cause osmotic demyelination (central pontine myelinolysis), so sodium is checked often.
Answer
A · Raising sodium too fast can cause osmotic demyelination in the brain
13.Med-surg: cardiovascular & respiratory
Answer: C · A sudden high potassium level can cause cardiac arrest
Why this is the answer
Rapid or concentrated IV potassium can cause cardiac arrest. It is given diluted, by infusion, at controlled rates (often with a pump and ECG monitoring for higher rates). Concentrated ampoules are tightly controlled in hospitals because of fatal errors.
Answer
C · A sudden high potassium level can cause cardiac arrest
14.Med-surg: cardiovascular & respiratory
Answer: C · Intravenous calcium gluconate or chloride
Why this is the answer
Severe hyperkalaemia with ECG changes is an emergency. IV calcium stabilises the myocardium within minutes. Insulin with glucose and nebulised salbutamol shift potassium into cells, and the cause (here spironolactone and the ACE inhibitor) is stopped. Cardiac monitoring is essential.
Answer
C · Intravenous calcium gluconate or chloride
15.Med-surg: neuro, endocrine & renal
Answer: A · They bind food phosphate that the kidneys cannot excrete
Why this is the answer
In CKD, phosphate retention leads to secondary hyperparathyroidism, renal bone disease and vascular calcification. Phosphate binders taken with meals bind dietary phosphate in the gut. Dietary phosphate is also limited.
Answer
A · They bind food phosphate that the kidneys cannot excrete
16.Med-surg: neuro, endocrine & renal
Answer: D · Renal vein thrombosis
Why this is the answer
Loss of anticoagulant proteins in nephrotic syndrome raises the risk of thrombosis, including in the renal vein. This can cause loin pain, haematuria and worse kidney function. Imaging and anticoagulation are needed.
Answer
D · Renal vein thrombosis
17.Med-surg: GI, perioperative & oncology
Answer: A · Use a dedicated lumen and strict aseptic technique
Why this is the answer
PN is rich in nutrients that bacteria can use. A dedicated lumen, aseptic non-touch technique and hanging limits reduce catheter-related bloodstream infection.
Answer
A · Use a dedicated lumen and strict aseptic technique
18.Med-surg: GI, perioperative & oncology
Answer: C · Perforation with peritonitis
Why this is the answer
Brief relief can occur when an inflamed appendix ruptures, followed by spreading peritonitis with fever, rigidity and tachycardia. This is a surgical emergency needing urgent review, IV fluids and antibiotics.
Answer
C · Perforation with peritonitis
19.Maternity & obstetric nursing
Answer: B · Abdominal pain, a firm or rigid uterus and dark red bleeding
Why this is the answer
Abruption causes pain, uterine tenderness and rigidity, and dark bleeding. The bleeding can be hidden behind the placenta, so blood loss may be much larger than what is visible.
Answer
B · Abdominal pain, a firm or rigid uterus and dark red bleeding
20.Maternity & obstetric nursing
Answer: C · At 36 weeks with constant pain and a hard uterus
Why this is the answer
Constant pain with a hard, tender uterus suggests placental abruption, which can threaten mother and fetus even with little visible bleeding. The other symptoms are common discomforts.
Answer
C · At 36 weeks with constant pain and a hard uterus
21.Pediatric nursing
Answer: B · Oral rehydration solution
Why this is the answer
Oral rehydration solution has the right balance of sodium and glucose to promote water absorption. Juice, fizzy drinks and many sports drinks contain too much sugar and too little sodium and can worsen diarrhoea.
Answer
B · Oral rehydration solution
22.Pediatric nursing
Answer: C · Children with sickle cell disease have reduced spleen function and are at high risk of serious bacterial infection
Why this is the answer
Repeated infarction damages the spleen early in childhood (functional asplenia), so encapsulated bacteria can cause overwhelming sepsis. Fever needs urgent assessment and usually antibiotics.
Answer
C · Children with sickle cell disease have reduced spleen function and are at high risk of serious bacterial infection
23.Mental health nursing
Answer: A · It takes weeks to work and is not useful as an as-needed drug
Why this is the answer
Buspirone has little sedation and low dependence risk, but its effect builds up over weeks. It is taken regularly, not as needed.
Answer
A · It takes weeks to work and is not useful as an as-needed drug
24.Mental health nursing
Answer: B · Assess the patient, including his vital signs and level of sedation
Why this is the answer
After a medicine error, the first step is to assess and monitor the patient for any effects. The nurse then informs the prescriber and the nurse in charge, follows instructions, documents and reports the incident.
Answer
B · Assess the patient, including his vital signs and level of sedation
25.Nursing math & unit conversions
Answer: x = 122 gtt/min
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 ones place
122.307 → 2
Only the next digit decides
122.307 → 3
3 is 4 or less, so 2 stays.
The digits after it (07) are ignored: round once, never step by step.
Round
x = 122 gtt/min
Answer
x = 122 gtt/min
26.Nursing math & unit conversions
Answer: Hb = 8.4 g/dL
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Convert
Hb = 84 g/L × (1 L/10 dL) = 8.4 g/dL
Answer
Hb = 8.4 g/dL
27.Dosage calculations
Answer: D = 600 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.
Dose
20·30 = 600 mg
Answer
D = 600 mg
28.Dosage calculations
Answer: V = 0.28 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 = 280/1000 = 0.28 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.28 mL
29.IV infusion rates
Answer: V = 120 mL
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.
Rate in mL/h
20·60/20 = 60 mL/h
Volume
V = 60·2 = 120 mL
Answer
V = 120 mL
30.IV infusion rates
Answer: Δ = 25 %
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
1000/10 = 100 mL/h
New rate
R = 500/4 = 125 mL/h
Percentage change
Δ = (125 − 100)/100·100% = 25%
Answer
Δ = 25%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: R = 3 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.
Concentration
100/100 = 1 units/mL
Pump rate
R = 3/1 = 3 mL/h
Answer
R = 3 mL/h
32.Pediatric & critical-care dosing
Answer: R = 30 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
4 000/250 = 16 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
8·60 = 480 mcg/h
Pump rate
R = 480/16 = 30 mL/h
Answer
R = 30 mL/h
33.IV fluids & fluid balance
Answer: U = 1.8 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
250 + 225 + 375 + 375 = 1225 mL
Per kilogram per hour
U = 1225/(85·8) = 1.801 ≈ 1.8 mL/kg/h
Answer
U = 1.8 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 2 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 − 200 = 300 mL
Time
t = 300/150 = 2 h
Answer
t = 2 h
That is about 2 h 00 min, so the bag runs out at about 12:00.
35.Clinical assessment scores
Answer: NEWS2 = 4
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 16/min → 0
SpO₂ 96% → 0
on air → 0
SBP 84 mmHg → 3
HR 70/min → 0
alert (A) → 0
T 38.8 °C → 1
Add
NEWS2 = 0 + 0 + 0 + 3 + 0 + 0 + 1 = 4
Answer
NEWS2 = 4
36.Clinical assessment scores
Answer: DBP = 42 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 − 111)/2 = 84/2 = 42 mmHg
Answer
DBP = 42 mmHg
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 35.2 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
|72 − 40| = 32 mmHg → 3.2 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·3.2 = 35.2 mmol/L
Answer
HCO₃⁻ = 35.2 mmol/L
38.Arterial blood gas interpretation
Answer: A–a gradient = 142.3 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.
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 12.5 × 0.04 = 0.50 s
RR = 26 × 0.04 = 1.04 s
Bazett’s formula
QTc = 0.50/√1.04 = 0.50/1.02 = 0.49 s
Answer
QTc = 0.49 s
Above the usual limits for both men (about 0.45 s) and women (about 0.46 s): prolonged. (490 ms)
40.ECG rhythm strip interpretation
Answer: ventricular rate = 50 bpm
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.
Atrial rate
P–P = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 ≈ 75 per minute
Ventricular rate
R–R = 30 small boxes = 1.20 s → 1500 ÷ 30 = 50 ≈ 50 per minute
Answer
ventricular rate = 50 bpm
Answer
ventricular rate = 50 bpm
Third-degree block with a narrow-complex junctional escape (usually 40–60 per minute).
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