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
What happens in the evaluation step of the nursing process?
AThe nurse collects the patient's history and baseline observations for the first time
BThe nurse writes the discharge letter for the doctor
CThe nurse checks whether the goals have been met and adjusts the plan
DThe nurse carries out the planned interventions
2.Nursing fundamentalsHard
An 82-year-old takes nine regular medicines and has had two falls this month. What is the most useful next step?
AAdvise the patient to stay in bed
BStop all the medicines straight away
CAdd a sedative to help them rest
DAsk for a full medication review
3.Infection control & patient safetyMedium
Two patients with very similar names are on the same unit. What is the best safety measure?
ATransfer one of the two patients to another hospital
BCall each patient by their first name only
CFlag the similar names and check two identifiers every time
DUse the room numbers to tell the patients apart
4.Infection control & patient safetyHard
A patient has a rash, and both smallpox and chickenpox are considered. Which finding suggests smallpox?
ASmall crops of new lesions appearing over several days in a row
BLesions all at the same stage, most dense on the face and limbs
CLesions at different stages, most dense on the trunk
DA rash that is very itchy and starts on the trunk
5.Prioritization & delegationMedium
One hour after a vaginal birth, the nurse finds a soft, boggy uterus and heavy bleeding. What is the first action?
AOffer a meal and fluids
BApply an ice pack to the perineum
CMassage the fundus
DEncourage the patient to rest quietly
6.Prioritization & delegationHard
A patient after major surgery has a urine output of 15 mL/h for two hours, a heart rate of 115/min and cool hands. What should the nurse do first?
AAssess for signs of shock, such as bleeding, and escalate
BWait another two hours to see whether the output improves
CEncourage the patient to drink more water and recheck later
DFlush the catheter and recheck the output tomorrow morning
7.Clinical nursingMedium
A new colostomy stoma appears dark purple to black on the second postoperative day. What does this indicate?
AA normal healthy stoma
BNormal postoperative bruising of the stoma that needs no action
CPossible ischaemia of the stoma, which needs urgent review
DConstipation
8.Clinical nursingHard
A patient has had diarrhoea for three days and is on a medical ward. What is the most appropriate infection control action?
AMove the patient to a shared bay so single rooms stay available
BUse alcohol hand rub only and avoid gloves to save resources
CWait until the diarrhoea has lasted a week before taking any action
DIsolate promptly, use contact precautions and send a stool sample
9.Lab values & electrolytesMedium
In the US, when is a pregnant woman without known risk factors usually screened for gestational diabetes?
AAt about 24–28 weeks of pregnancy
BAt about 38–40 weeks of pregnancy
CAt about 6–8 weeks of pregnancy
DOnly after the baby is born
10.Lab values & electrolytesHard
A patient using an insulin pump has a glucose of 300 mg/dL (16.7 mmol/L) that has not fallen 2 hours after a correction bolus through the pump. Blood ketones are 1.8 mmol/L. What is the most likely problem and action?
ARebound after a hypo; give fast-acting carbohydrate and recheck in 15 minutes
BInsulin overdose from the pump; suspend the pump and stop all insulin for a day
CInsulin delivery failure; inject a correction dose by pen and change the set
DNormal pump function; wait for the next mealtime bolus to lower the glucose
11.PharmacologyMedium
Digoxin 0.25 mg is ordered. The tablets available are 0.125 mg. How many tablets should be given?
A0.5 tablet
B1 tablet
C4 tablets
D2 tablets
12.PharmacologyHard
A baby born to a mother on methadone becomes irritable on day 2, with a high-pitched cry, tremors, sneezing and poor feeding. What is the most likely cause?
AVitamin K deficiency bleeding
BNeonatal hypoglycaemia from maternal diabetes
CNeonatal opioid withdrawal syndrome
DNormal newborn behaviour
13.Med-surg: cardiovascular & respiratoryMedium
Which pneumonia severity score uses confusion, urea, respiratory rate, blood pressure and age?
ANEWS2
BWells score
CCURB-65
DCHA₂DS₂-VASc
14.Med-surg: cardiovascular & respiratoryHard
A patient with severe COPD has increasing ankle oedema and a raised JVP, but no crackles and a normal left ventricle on echocardiography. Which condition is most likely?
ACor pulmonale
BDeep vein thrombosis
CAortic stenosis
DLeft ventricular failure
15.Med-surg: neuro, endocrine & renalMedium
When a patient sticks out their tongue, it points to the right. Which nerve is affected?
AThe left trigeminal nerve (V)
BThe left hypoglossal nerve (XII)
CThe right hypoglossal nerve (XII)
DThe right facial nerve (VII)
16.Med-surg: neuro, endocrine & renalHard
A patient on levothyroxine has palpitations, weight loss and poor sleep. TSH is suppressed, and free T4 is high. What is the most likely explanation?
AThe dose is too high
BThe dose is too low
CA normal response to the drug
DThe thyroid has stopped working
17.Med-surg: GI, perioperative & oncologyMedium
Why are many patients screened for MRSA before planned surgery?
ATo check whether the patient has had a flu vaccine
BSo that surgery can be cancelled for all positive patients
CTo decide which anaesthetic drug to use
DSo that carriers can be decolonised to reduce infection
18.Med-surg: GI, perioperative & oncologyHard
A patient asks whether to take their usual bisoprolol on the morning of surgery. What is the usual guidance?
ATake it only after the operation is finished
BTake a double dose to protect the heart
CUsually continue it with a sip of water, unless told otherwise
DStop it one week before any operation
19.Maternity & obstetric nursingMedium
How can a cephalhaematoma be told apart from caput succedaneum?
AA cephalhaematoma crosses the midline of the skull
BA cephalhaematoma is present at birth and disappears within a few days
CA cephalhaematoma does not cross the suture lines
DA cephalhaematoma is a soft swelling of the scalp skin only
20.Maternity & obstetric nursingHard
A woman with gestational diabetes on insulin asks about her baby after birth. Which statement by the nurse is accurate?
AThe baby's glucose will be checked for hypoglycaemia
BThe baby will be born with diabetes
CThe baby will need insulin for the first days
DThe baby must not be breastfed in the first week
21.Pediatric nursingMedium
A 2-year-old suddenly began coughing while eating peanuts. He now has a wheeze on one side of the chest only. What is most likely?
AAn inhaled foreign body
BA first attack of asthma
CBronchiolitis
DViral croup
22.Pediatric nursingHard
A child is receiving IV potassium chloride. The nurse finds the cannula site swollen and pale and the child crying. What should the nurse do first?
AIncrease the infusion rate to finish faster
BStop the infusion and assess the site
CApply a tight bandage over the site
DReassure the child and continue the infusion
23.Mental health nursingMedium
What is assertive community treatment (ACT)?
ACompulsory hospital treatment for people who refuse medicine
BIntensive team-based support at home for people with severe mental illness and frequent admissions
CA short course of assertiveness training for people with mild social anxiety
DA self-help group run entirely by former patients, without any professional staff or support at all
24.Mental health nursingHard
The parent of a 16-year-old taking a stimulant for ADHD says her son's friends keep asking him for his tablets. What should the nurse teach?
AStop the medicine so that there is no risk of sharing
BGive the friends a smaller dose if they ask, so that they do not have side effects
CStore it securely and never share it, because stimulants are controlled drugs
DSharing is fine as long as the friends are the same age
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for an injection gives 11.7817 mL. The rule in this exercise is that volumes of 1 mL or more are rounded to the nearest tenth of a mL. What value x do you record?
11.7817 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 20 mcg/min. Express this dose rate D in mg/h.
20 mcg/min1 h = 60 min1 mg = 1000 mcg
D = mg/h
27.Dosage calculationsMedium
A patient weighs 80 kg and is prescribed 2 mg/kg as a single dose. Find the dose D in mg.
80 kg2 mg/kg
D = mg
28.Dosage calculationsHard
The prescription is 1.62 mg. The ampoule contains 2000 micrograms per mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
1.62 mg2000 mcg/mL
V = mL
29.IV infusion ratesMedium
1500 mL was ordered over 6 hours. After 4 hours you find that 630 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?
1500 mL / 6 hafter 4 h: 630 mL
R = mL/h
30.IV infusion ratesHard
200 mg of a drug is diluted in 100 mL and given by gravity through a set of 60 gtt/mL. The order is 100 mg per hour. Find the drip rate R in drops per minute.
200 mg/100 mL100 mg/h60 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 50 mL. The order is 6 units/h. Find the pump rate R in mL/h. Round to one decimal place.
100 units/50 mL6 units/h
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 7.5 mcg/kg/min for a patient who weighs 81 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
500 mg/250 mL7.5 mcg/kg/min81 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
jelly: 120 mLtea: 240 mLsoup: 150 mLIV infusion: 60 mL/h × 12 hIV antibiotic: 1 × 50 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 150 mL/h. At 08:00, 50 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL50 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 14/min, SpO₂ 96% on room air, blood pressure 92/56 mmHg, pulse 58/min, alert, temperature 38.1 °C. What is the NEWS2 total score?
RR 14SpO₂ 96%airSBP 92HR 58AT 38.1 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 88 kg and is 179 cm tall. Calculate the BMI and click the WHO weight category.
88 kg179 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.53, PaCO₂ 49 mmHg (6.5 kPa) and HCO₃⁻ 40 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.53PaCO₂ 49 mmHg (6.5 kPa)HCO₃⁻ 40 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 24% oxygen shows PaO₂ 71 mmHg (9.5 kPa) and PaCO₂ 32 mmHg (4.3 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
This lead II strip shows atrial flutter. How many flutter waves per QRS complex are there (the n of n:1 conduction)?
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
flutter waves per QRS =
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
1ventricular paced rhythm
2sinus rhythm with wide QRS
3idioventricular rhythm
4dual-chamber (AV) paced rhythm
3Solutions
1.Nursing fundamentals
Answer: C · The nurse checks whether the goals have been met and adjusts the plan
Why this is the answer
Evaluation compares the patient's outcome with the planned goals. If goals are not met, the nurse reassesses and changes the care plan.
Answer
C · The nurse checks whether the goals have been met and adjusts the plan
2.Nursing fundamentals
Answer: D · Ask for a full medication review
Why this is the answer
Polypharmacy increases the risk of falls, side effects and interactions in older adults. A review by the prescriber or pharmacist can stop or adjust medicines safely.
Answer
D · Ask for a full medication review
3.Infection control & patient safety
Answer: C · Flag the similar names and check two identifiers every time
Why this is the answer
Name-alert systems, such as stickers or flags, warn staff, and strict checking of two identifiers prevents mix-ups. Room numbers and first names are not reliable.
Answer
C · Flag the similar names and check two identifiers every time
4.Infection control & patient safety
Answer: B · Lesions all at the same stage, most dense on the face and limbs
Why this is the answer
In smallpox, lesions develop at the same stage in any one area and are densest on the face and extremities. In chickenpox, crops appear at different stages and are densest on the trunk.
Answer
B · Lesions all at the same stage, most dense on the face and limbs
5.Prioritization & delegation
Answer: C · Massage the fundus
Why this is the answer
Uterine atony is the most common cause of postpartum hemorrhage. Fundal massage helps the uterus contract; the nurse then calls for help and gives prescribed uterotonics if bleeding continues.
Answer
C · Massage the fundus
6.Prioritization & delegation
Answer: A · Assess for signs of shock, such as bleeding, and escalate
Why this is the answer
These signs together suggest hypovolemia or shock. The nurse assesses the whole patient, looks for bleeding and escalates. A catheter problem should be ruled out, but it should not delay recognition of shock.
Answer
A · Assess for signs of shock, such as bleeding, and escalate
7.Clinical nursing
Answer: C · Possible ischaemia of the stoma, which needs urgent review
Why this is the answer
A dusky or black stoma suggests poor blood supply and possible necrosis, and must be reported promptly to the surgical team.
Answer
C · Possible ischaemia of the stoma, which needs urgent review
8.Clinical nursing
Answer: D · Isolate promptly, use contact precautions and send a stool sample
Why this is the answer
Unexplained diarrhoea may be infective, for example C. difficile or norovirus. Isolation and testing without delay protect other patients.
Answer
D · Isolate promptly, use contact precautions and send a stool sample
9.Lab values & electrolytes
Answer: A · At about 24–28 weeks of pregnancy
Why this is the answer
Placental hormones increase insulin resistance in the second half of pregnancy, so US guidance recommends screening all women at 24–28 weeks, with earlier testing for those with risk factors. In the UK, NICE recommends an oral glucose tolerance test at 24–28 weeks only for women with risk factors.
Answer
A · At about 24–28 weeks of pregnancy
10.Lab values & electrolytes
Answer: C · Insulin delivery failure; inject a correction dose by pen and change the set
Why this is the answer
A high glucose that does not respond to a pump bolus, with rising ketones, suggests a kinked, blocked or dislodged cannula. Because pumps use only rapid-acting insulin, DKA can develop within hours. The usual advice is to give a correction dose by pen or syringe, change the infusion set, check glucose and ketones often, and seek help if ketones keep rising or vomiting starts.
Answer
C · Insulin delivery failure; inject a correction dose by pen and change the set
11.Pharmacology
Answer: D · 2 tablets
Why this is the answer
0.25 mg ÷ 0.125 mg = 2 tablets. Doses that need more than a few tablets or unusual fractions should be double-checked.
Answer
D · 2 tablets
12.Pharmacology
Answer: C · Neonatal opioid withdrawal syndrome
Why this is the answer
After birth the baby no longer receives opioid from the mother and develops withdrawal. Assessment uses a scoring tool, with non-drug care first and opioid treatment if signs are severe.
Answer
C · Neonatal opioid withdrawal syndrome
13.Med-surg: cardiovascular & respiratory
Answer: C · CURB-65
Why this is the answer
CURB-65 gives one point each for Confusion, Urea >7 mmol/L, Respiratory rate ≥30/min, low Blood pressure (systolic <90 or diastolic ≤60 mmHg) and age ≥65. Higher scores mean higher mortality and the need for hospital or critical care.
Answer
C · CURB-65
14.Med-surg: cardiovascular & respiratory
Answer: A · Cor pulmonale
Why this is the answer
Chronic hypoxia in COPD causes pulmonary hypertension, which strains the right ventricle and leads to right heart failure with oedema and raised JVP. Management includes treating hypoxia (long-term oxygen if eligible), diuretics for oedema and optimising COPD treatment.
Answer
A · Cor pulmonale
15.Med-surg: neuro, endocrine & renal
Answer: C · The right hypoglossal nerve (XII)
Why this is the answer
With a lower motor neuron lesion of the hypoglossal nerve, the tongue deviates towards the side of the lesion, because the healthy muscles push it across. Wasting and fasciculation of that side may also be seen.
Answer
C · The right hypoglossal nerve (XII)
16.Med-surg: neuro, endocrine & renal
Answer: A · The dose is too high
Why this is the answer
A suppressed TSH with raised free T4 and hyperthyroid symptoms in a patient on levothyroxine suggests over-replacement. The prescriber usually lowers the dose. Long-term over-replacement increases the risk of atrial fibrillation and bone loss.
Answer
A · The dose is too high
17.Med-surg: GI, perioperative & oncology
Answer: D · So that carriers can be decolonised to reduce infection
Why this is the answer
MRSA carriers have a higher risk of surgical site infection. Screening allows decolonisation with nasal ointment and skin washes, and the right antibiotic prophylaxis.
Answer
D · So that carriers can be decolonised to reduce infection
18.Med-surg: GI, perioperative & oncology
Answer: C · Usually continue it with a sip of water, unless told otherwise
Why this is the answer
Beta-blockers are usually continued around surgery because sudden withdrawal can cause rebound tachycardia and ischaemia. The patient follows the specific instructions from the preoperative assessment.
Answer
C · Usually continue it with a sip of water, unless told otherwise
19.Maternity & obstetric nursing
Answer: C · A cephalhaematoma does not cross the suture lines
Why this is the answer
Caput is oedema of the scalp, present at birth, crossing sutures and resolving within days. A cephalhaematoma is a subperiosteal bleed limited by the sutures; it appears after birth, lasts weeks and can increase jaundice.
Answer
C · A cephalhaematoma does not cross the suture lines
20.Maternity & obstetric nursing
Answer: A · The baby's glucose will be checked for hypoglycaemia
Why this is the answer
Babies of mothers with diabetes may have high insulin levels after birth, causing hypoglycaemia. Early, frequent feeding, often skin-to-skin, and glucose monitoring per protocol are standard.
Answer
A · The baby's glucose will be checked for hypoglycaemia
21.Pediatric nursing
Answer: A · An inhaled foreign body
Why this is the answer
A sudden cough or choking episode while eating, followed by a one-sided wheeze or reduced breath sounds, strongly suggests foreign body aspiration. It needs urgent assessment and usually removal by bronchoscopy.
Answer
A · An inhaled foreign body
22.Pediatric nursing
Answer: B · Stop the infusion and assess the site
Why this is the answer
Swelling, pallor and pain suggest extravasation or infiltration. Stop the infusion, assess the site, follow the local extravasation protocol and inform the prescriber. Irritant infusions can damage tissue.
Answer
B · Stop the infusion and assess the site
23.Mental health nursing
Answer: B · Intensive team-based support at home for people with severe mental illness and frequent admissions
Why this is the answer
ACT teams provide frequent, flexible, multidisciplinary support in people's homes and communities, including help with medicines, housing and daily living. It aims to reduce hospital admissions.
Answer
B · Intensive team-based support at home for people with severe mental illness and frequent admissions
24.Mental health nursing
Answer: C · Store it securely and never share it, because stimulants are controlled drugs
Why this is the answer
Stimulants can be diverted and misused for studying or recreation. They are controlled drugs, so secure storage, monitoring the number of tablets and not sharing them are important.
Answer
C · Store it securely and never share it, because stimulants are controlled drugs
25.Nursing math & unit conversions
Answer: x = 11.8 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the tenths place
11.7817 → 7
Only the next digit decides
11.7817 → 8
8 is 5 or more, so round 7 up.
The digits after it (17) are ignored: round once, never step by step.
Round
x = 11.8 mL
Answer
x = 11.8 mL
26.Nursing math & unit conversions
Answer: D = 1.2 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 = 20 mcg/min × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 20·60/1000 = 1.2 mg/h
Answer
D = 1.2 mg/h
27.Dosage calculations
Answer: D = 160 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
2·80 = 160 mg
Answer
D = 160 mg
28.Dosage calculations
Answer: V = 0.81 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.
Same units
1.62 mg = 1620 mcg
Volume
V = 1620/2000 = 0.81 mL
Answer
V = 0.81 mL
29.IV infusion rates
Answer: R = 315 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
1500/6 = 250 mL/h
New rate
R = 630/2 = 315 mL/h
Answer
R = 315 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: R = 50 gtt/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
200/100 = 2 mg/mL
Volume per hour
100/2 = 50 mL/h
Drip rate
R = 50·60/60 = 50 gtt/min
Answer
R = 50 gtt/min
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
100/50 = 2 units/mL
Pump rate
R = 6/2 = 3 mL/h
Answer
R = 3 mL/h
32.Pediatric & critical-care dosing
Answer: R = 18.2 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
7.5·81 = 607.5 mcg/min
607.5·60 = 36450 mcg/h
Pump rate
R = 36450/2000 = 18.23 ≈ 18.2 mL/h
Answer
R = 18.2 mL/h
33.IV fluids & fluid balance
Answer: I = 1280 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Add the intake
oral: 120 + 240 + 150 = 510 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 1·50 = 50 mL
I = 1280 mL
Answer
I = 1280 mL
34.IV fluids & fluid balance
Answer: t = 3 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 − 50 = 450 mL
Time
t = 450/150 = 3 h
Answer
t = 3 h
That is about 3 h 00 min, so the bag runs out at about 11:00.
35.Clinical assessment scores
Answer: NEWS2 = 3
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 14/min → 0
SpO₂ 96% → 0
on air → 0
SBP 92 mmHg → 2
HR 58/min → 0
alert (A) → 0
T 38.1 °C → 1
Add
NEWS2 = 0 + 0 + 0 + 2 + 0 + 0 + 1 = 3
Answer
NEWS2 = 3
36.Clinical assessment scores
Answer: overweight
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 = 88/1.79² = 27.46
Category
overweight
Answer
overweight
37.Arterial blood gas interpretation
Answer: partially compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.53: alkalaemia (above 7.45)
PaCO₂ 49 mmHg: high (35–45)
HCO₃⁻ 40 mmol/L: high (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: A–a gradient = 60.12 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.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 10 small boxes = 0.40 s → 1500 ÷ 10 = 150 per minute
conduction ratio = 300 ÷ 150 = 2:1
Answer
flutter waves per QRS = 2
40.ECG rhythm strip interpretation
Answer: ventricular paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 21 small boxes, 1500 ÷ 21 ≈ 71 per minute.
2. Rhythm: regular, every R–R is 0.84 s.
3. P waves: none visible; a sharp pacing spike comes just before every QRS.
4. PR interval: not measurable.
5. QRS: 0.16 s, wide, and every spike is followed by a QRS (capture).
Interpretation
ventricular paced rhythm
Answer
ventricular paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.