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 is medicines reconciliation on admission?
ACounting the tablets in the ward drug trolley at the start of each shift
BChanging all the patient's medicines to hospital brands
CGetting an accurate list of the medicines taken before admission
DOrdering new stock from the pharmacy
2.Nursing fundamentalsHard
A healthcare assistant (nursing assistant) has recorded a blood pressure of 82/50 mmHg during routine observations but did not report it. What should the registered nurse do first?
ARepeat the observations at the next routine time
BAssess the patient straight away
CComplete an incident report
DTalk to the healthcare assistant about reporting
3.Infection control & patient safetyMedium
Why does a nurse wear chemotherapy-tested gloves and a gown when emptying the urinal of a patient who recently had chemotherapy?
AThe urine always contains infectious bacteria after chemotherapy
BThe patient is on airborne precautions after treatment
CChemotherapy makes the urine strongly acidic and corrosive
DThe body fluids can contain active drug for a time after treatment
4.Infection control & patient safetyHard
A nurse often skips barcode scanning to save time, as many colleagues do. In a just culture, how is this behavior classed?
ASimple human error, managed only by consoling the nurse and moving on
BAt-risk behavior, managed by coaching and fixing the system pressures behind it
CReckless behavior, managed by immediate dismissal and reporting to the licensing board
DAcceptable behavior, because it is common on the unit
5.Prioritization & delegationMedium
A patient wants to leave the hospital against medical advice. What should the nurse do?
AInform the provider, explain the risks and document the discussion
BLock the door so the patient cannot leave the unit
CLet the patient leave without telling anyone
DHide the patient’s clothes and belongings until the provider arrives
6.Prioritization & delegationHard
A dehydrated child is to receive IV fluids with added potassium. Which finding should the nurse confirm first?
AThat the child is hungry
BThat the child’s temperature is normal
CThat the child can walk without help
DThat the child is passing urine
7.Clinical nursingMedium
Which features suggest pyelonephritis rather than simple cystitis?
AFrequency without any pain
BFever, rigors and loin pain
CCloudy urine with no other symptoms
DMild burning on passing urine only
8.Clinical nursingHard
Why must a unit of red cells be transfused within the set time limit (commonly four hours) after it leaves controlled cold storage?
AThe blood group of the cells changes after a few hours
BThe red cells break down and turn into plasma
CBacteria can grow in the blood at room temperature
DThe bag stops dripping after four hours
9.Lab values & electrolytesMedium
The laboratory phones the ward with a critical potassium result of 6.9 mEq/L. What should the nurse do?
ARead back the value, assess the patient and inform the provider
BWait for the written report to arrive before taking any action at all
CAsk the laboratory to repeat the test before telling anyone
DRecord the value and hand it over to the next shift
10.Lab values & electrolytesHard
A patient taking isoniazid for latent TB reports nausea, loss of appetite and dark urine. The ALT is five times the upper limit of normal. What is the best action?
AContinue the isoniazid and give it with food to settle the stomach
BReassure the patient that dark urine is a harmless drug effect
CDouble the dose to finish the treatment course more quickly
DHold the isoniazid and report the findings to the prescriber at once
11.PharmacologyMedium
Why do NSAIDs such as ibuprofen increase the risk of stomach ulcers?
AThey reduce protective prostaglandins in the stomach lining
BThey raise the pH of gastric acid
CThey directly dissolve the mucus layer
DThey increase the number of Helicobacter pylori bacteria in the stomach
12.PharmacologyHard
Probenecid has been used to raise plasma penicillin levels. How does it do this?
AIt inhibits the liver metabolism of penicillin
BIt increases the absorption of penicillin from the small intestine
CIt blocks the tubular secretion of penicillin in the kidney
DIt displaces penicillin from plasma proteins
13.Med-surg: cardiovascular & respiratoryMedium
Which investigation is usually used to confirm a deep vein thrombosis in the leg?
ACompression duplex ultrasound
BAn exercise ECG
CA lung function test
DA plain chest X-ray and an ECG
14.Med-surg: cardiovascular & respiratoryHard
An 82-year-old with community-acquired pneumonia is newly confused, with RR 32/min, BP 88/52 mmHg and urea 9 mmol/L. What does this indicate?
AA CURB-65 score of 1: suitable for oral antibiotics at home
BA CURB-65 score of 5: high risk needing urgent senior review
CA normal response to infection in an older adult
DA CURB-65 score of 3: routine admission to a general ward only
15.Med-surg: neuro, endocrine & renalMedium
Which measure best detects a decline in breathing in a patient with Guillain–Barré syndrome?
ARegular forced vital capacity measurements
BDaily chest X-rays
CPeak flow before and after a bronchodilator
DOxygen saturation alone
16.Med-surg: neuro, endocrine & renalHard
A patient with a subarachnoid haemorrhage develops a low sodium. Why is fluid restriction usually avoided in this patient?
ALow sodium in this condition always corrects itself
BFluid restriction would cause the aneurysm to re-bleed
CFluid restriction raises the risk of seizures
DLow blood volume can worsen vasospasm and brain ischaemia
17.Med-surg: GI, perioperative & oncologyMedium
Which is a usual benefit of laparoscopic over open abdominal surgery?
ANo risk of any complications at all
BNo need for a general anaesthetic ever
CLess pain and a shorter hospital stay
DLarger wounds that heal faster
18.Med-surg: GI, perioperative & oncologyHard
A patient has sharp, tearing pain on passing stool, "like passing glass", with a streak of fresh blood. Which condition is most likely?
AColorectal cancer
BUpper GI bleeding
CAnal fissure
DCrohn's disease of the ileum
19.Maternity & obstetric nursingMedium
A woman is about to get out of bed for the first time after birth. What should the nurse do?
AWait until day 3 before letting her stand
BAsk her to stand quickly to reduce dizziness
CHelp her sit, then stand slowly with support
DLet her walk alone so she feels independent
20.Maternity & obstetric nursingHard
A pregnant woman involved in a car crash asks how to wear a seat belt. Which instruction is correct?
APut the lap belt across the top of the bump, above the uterus
BWear only the shoulder part of the belt
CDo not wear a seat belt in pregnancy
DLap belt under the bump, shoulder belt between the breasts
21.Pediatric nursingMedium
What is the main purpose of medical play with a doll and real equipment before surgery?
ATo test the child's intelligence
BTo teach the child how the surgeons will do the operation
CTo let the child express fears and gain a sense of control
DTo keep the child busy so the nurse can do other work
22.Pediatric nursingHard
An 8-year-old tells the nurse that her uncle touches her in a way she does not like and asks the nurse to keep it secret. What is the best response?
APhone the uncle straight away to ask for his side of the story before reporting anything
BPromise to keep the secret, so that she keeps trusting the nurse and tells more later
CAsk detailed, leading questions to find out exactly what happened
DListen calmly, praise her for telling, explain it must be shared, and follow safeguarding
23.Mental health nursingMedium
A patient shouts at the nurse, "You're useless! You never help me!" Which response is most therapeutic?
A"You shouldn't talk to people like that."
B"You sound very angry. Tell me what has happened."
C"That's not true. I've helped you all day."
D"If you speak to me like that, I'm leaving."
24.Mental health nursingHard
A patient with anorexia nervosa is found doing sit-ups in her room after every meal. What is the best nursing response?
ATell her she will be tube-fed if she does it again
BIgnore it, because exercise is always healthy
CCalmly follow the agreed care plan on activity and observation, without arguing or punishing
DPraise her for being so active and motivated, because it shows she is taking care of her health
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 98.3 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
98.3 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 20:00 and finishes at 05:00 the next morning (24-hour clock). How many minutes t did it run?
20:0005:00
t = min
27.Dosage calculationsMedium
A patient weighs 25 kg. The prescribed dose is 2 mg/kg per day, given in 3 equal doses. How many milligrams D are given per dose?
25 kg2 mg/kg/day3× per day
D = mg
28.Dosage calculationsHard
An infusion contains 25000 units of a drug in 1000 mL. The prescription is 1200 units per hour. At what rate R do you set the pump, in mL/h?
25000 units/1000 mL1200 units/h
R = mL/h
29.IV infusion ratesMedium
1000 mL was ordered over 8 hours. After 4 hours you find that 640 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?
1000 mL / 8 hafter 4 h: 640 mL
R = mL/h
30.IV infusion ratesHard
1500 mL was ordered over 10 hours. After 3 hours you find that 1260 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?
1500 mL / 10 hafter 3 h: 1260 mL
Δ = %
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 94 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg94 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 79 kg has an order for norepinephrine at 12 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 mL12 mcg/min79 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The patient weighs 84 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 1000 mL bag runs by pump at 80 mL/h. At 21:00, 200 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL200 mL infused80 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 15, with E4 and V5. What motor score M was recorded, and which response does it describe? Give the number.
GCS 15E4V5
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). At 1 minute after birth, a practice newborn has blue or pale skin all over, no heartbeat, no response to stimulation, limp limbs with no muscle tone and no breathing. Score the APGAR and click how the score is interpreted.
1reassuring
2moderately abnormal
3low
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 53 mmHg (7.1 kPa). Use the rule that in acute respiratory acidosis HCO₃⁻ rises by 1 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows pH 7.32, PaCO₂ 30 mmHg (4.0 kPa) and HCO₃⁻ 15 mmol/L, with Na⁺ 145 and Cl⁻ 107 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
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
Identify the rhythm on this 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 fibrillation
2asystole
3sinus bradycardia
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: C · Getting an accurate list of the medicines taken before admission
Why this is the answer
Medicines reconciliation compares the patient's own medicines with what is prescribed in hospital, using several sources, so that changes are intended and errors are avoided.
Answer
C · Getting an accurate list of the medicines taken before admission
2.Nursing fundamentals
Answer: B · Assess the patient straight away
Why this is the answer
A low blood pressure may mean deterioration, so the nurse assesses the patient at once and escalates if needed. Feedback to the assistant and reporting follow afterwards.
Answer
B · Assess the patient straight away
3.Infection control & patient safety
Answer: D · The body fluids can contain active drug for a time after treatment
Why this is the answer
Many hazardous drugs are excreted in urine, stool and vomit for a period after treatment. Staff wear protective gloves and gowns when handling these fluids, according to policy.
Answer
D · The body fluids can contain active drug for a time after treatment
4.Infection control & patient safety
Answer: B · At-risk behavior, managed by coaching and fixing the system pressures behind it
Why this is the answer
At-risk behavior is a choice whose risk is not recognized or is believed to be justified, often because shortcuts have become normal. It is managed by coaching and removing the pressures behind it, while reckless behavior may need disciplinary action.
Answer
B · At-risk behavior, managed by coaching and fixing the system pressures behind it
5.Prioritization & delegation
Answer: A · Inform the provider, explain the risks and document the discussion
Why this is the answer
A competent adult has the right to leave. The nurse informs the provider, makes sure the patient understands the risks and documents it; holding the patient against their will may be false imprisonment.
Answer
A · Inform the provider, explain the risks and document the discussion
6.Prioritization & delegation
Answer: D · That the child is passing urine
Why this is the answer
Potassium is not added to IV fluids until the child is passing urine, because poor kidney function can let potassium build up to dangerous levels.
Answer
D · That the child is passing urine
7.Clinical nursing
Answer: B · Fever, rigors and loin pain
Why this is the answer
Pyelonephritis is an upper urinary tract infection and causes systemic signs such as fever and rigors, with flank pain. Cystitis usually causes local symptoms such as dysuria and frequency.
Answer
B · Fever, rigors and loin pain
8.Clinical nursing
Answer: C · Bacteria can grow in the blood at room temperature
Why this is the answer
Red cells are stored cold to limit bacterial growth. Once out of controlled storage, the transfusion must be completed within the time limit to reduce the risk of bacterial contamination and transfusion-transmitted infection.
Answer
C · Bacteria can grow in the blood at room temperature
9.Lab values & electrolytes
Answer: A · Read back the value, assess the patient and inform the provider
Why this is the answer
Reading back a verbal result prevents errors. A critical value is reported to the provider without delay, and the nurse assesses the patient, including heart rhythm. A repeat sample may be needed, but it must not delay the response.
Answer
A · Read back the value, assess the patient and inform the provider
10.Lab values & electrolytes
Answer: D · Hold the isoniazid and report the findings to the prescriber at once
Why this is the answer
Isoniazid can cause hepatitis, which may be severe. Symptoms such as nausea, loss of appetite and dark urine with a markedly raised ALT mean the drug should be held and the prescriber informed. Patients are taught to avoid alcohol and report these symptoms early.
Answer
D · Hold the isoniazid and report the findings to the prescriber at once
11.Pharmacology
Answer: A · They reduce protective prostaglandins in the stomach lining
Why this is the answer
NSAIDs inhibit COX-1, lowering prostaglandins that maintain mucus, bicarbonate secretion and blood flow in the stomach lining.
Answer
A · They reduce protective prostaglandins in the stomach lining
12.Pharmacology
Answer: C · It blocks the tubular secretion of penicillin in the kidney
Why this is the answer
Penicillins are excreted largely by organic anion transporters in the proximal tubule. Probenecid competes for these transporters, so penicillin is excreted more slowly and its level stays higher.
Answer
C · It blocks the tubular secretion of penicillin in the kidney
13.Med-surg: cardiovascular & respiratory
Answer: A · Compression duplex ultrasound
Why this is the answer
Compression ultrasound shows whether a deep vein is compressible and whether flow is normal; a vein containing clot does not compress. A low clinical probability with a negative D-dimer can rule out DVT without imaging.
Answer
A · Compression duplex ultrasound
14.Med-surg: cardiovascular & respiratory
Answer: B · A CURB-65 score of 5: high risk needing urgent senior review
Why this is the answer
This patient scores 5 out of 5: confusion, urea >7 mmol/L, respiratory rate ≥30/min, low blood pressure and age ≥65. This indicates severe pneumonia with high mortality, and the patient also meets criteria for possible sepsis. Rapid escalation, IV antibiotics, fluids and assessment for critical care are needed.
Answer
B · A CURB-65 score of 5: high risk needing urgent senior review
15.Med-surg: neuro, endocrine & renal
Answer: A · Regular forced vital capacity measurements
Why this is the answer
In Guillain–Barré syndrome, the breathing muscles weaken progressively. A falling vital capacity shows this early, long before oxygen saturation drops. A weak cough and difficulty counting in one breath are other warning signs.
Answer
A · Regular forced vital capacity measurements
16.Med-surg: neuro, endocrine & renal
Answer: D · Low blood volume can worsen vasospasm and brain ischaemia
Why this is the answer
Hyponatraemia after subarachnoid haemorrhage may come from SIADH or cerebral salt wasting. Restricting fluid can cause hypovolaemia, which makes delayed cerebral ischaemia more likely. Sodium is usually corrected with fluids or salt under specialist advice.
Answer
D · Low blood volume can worsen vasospasm and brain ischaemia
17.Med-surg: GI, perioperative & oncology
Answer: C · Less pain and a shorter hospital stay
Why this is the answer
Smaller incisions usually mean less pain, faster mobilisation, fewer wound complications and shorter stays. There are still risks, including injury to organs and shoulder-tip pain from the gas.
Answer
C · Less pain and a shorter hospital stay
18.Med-surg: GI, perioperative & oncology
Answer: C · Anal fissure
Why this is the answer
An anal fissure causes severe pain during and after defecation with bright red blood. Treatment includes stool softeners, fibre and topical treatment to relax the sphincter.
Answer
C · Anal fissure
19.Maternity & obstetric nursing
Answer: C · Help her sit, then stand slowly with support
Why this is the answer
Orthostatic hypotension is common after birth. The nurse helps her sit at the edge of the bed, dangle her legs, then stand slowly with assistance and stays close in case she feels faint.
Answer
C · Help her sit, then stand slowly with support
20.Maternity & obstetric nursing
Answer: D · Lap belt under the bump, shoulder belt between the breasts
Why this is the answer
The lap belt should sit low under the abdomen across the hips and thighs, with the shoulder belt across the chest and to the side of the bump. Wearing a seat belt greatly reduces maternal and fetal injury.
Answer
D · Lap belt under the bump, shoulder belt between the breasts
21.Pediatric nursing
Answer: C · To let the child express fears and gain a sense of control
Why this is the answer
Therapeutic or medical play lets children explore equipment, act out procedures and show feelings they cannot put into words. It reduces anxiety and helps staff correct misunderstandings.
Answer
C · To let the child express fears and gain a sense of control
22.Pediatric nursing
Answer: D · Listen calmly, praise her for telling, explain it must be shared, and follow safeguarding
Why this is the answer
The nurse listens without showing shock, reassures the child, avoids leading questions, records her words accurately and explains that people who can help need to know. The concern is reported at once through the safeguarding procedure.
Answer
D · Listen calmly, praise her for telling, explain it must be shared, and follow safeguarding
23.Mental health nursing
Answer: B · "You sound very angry. Tell me what has happened."
Why this is the answer
A calm, non-defensive response that names the feeling invites the patient to explain the cause of the anger. Arguing or threatening tends to escalate the situation.
Answer
B · "You sound very angry. Tell me what has happened."
24.Mental health nursing
Answer: C · Calmly follow the agreed care plan on activity and observation, without arguing or punishing
Why this is the answer
Compensatory exercise undermines weight restoration. The team agrees clear limits and observation in the care plan and applies them consistently and without judgement, while exploring the feelings behind the behaviour.
Answer
C · Calmly follow the agreed care plan on activity and observation, without arguing or punishing
25.Nursing math & unit conversions
Answer: T = 36.8 °C
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Subtract 32
98.3 − 32 = 66.3
Multiply by 5/9
T = 66.3·5/9 = 36.83 ≈ 36.8 °C
Answer
T = 36.8 °C
26.Nursing math & unit conversions
Answer: t = 540 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
20:00 → 24:00 = 240 min
After midnight
00:00 → 05:00 = 300 min
Total
t = 240 + 300 = 540 min
Answer
t = 540 min
27.Dosage calculations
Answer: D = 16.67 mg
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Total per day
2·25 = 50 mg
Per dose
D = 50/3 = 16.67 mg
Answer
D = 16.67 mg
28.Dosage calculations
Answer: R = 48 mL/h
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
25000/1000 = 25 units/mL
Pump rate
R = 1200/25 = 48 mL/h
Answer
R = 48 mL/h
29.IV infusion rates
Answer: R = 160 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
1000/8 = 125 mL/h
New rate
R = 640/4 = 160 mL/h
Answer
R = 160 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: Δ = 20 %
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
1500/10 = 150 mL/h
New rate
R = 1260/7 = 180 mL/h
Percentage change
Δ = (180 − 150)/150·100% = 20%
Answer
Δ = 20%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: V = 7.5 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
80·94 = 7 520 units
Volume
V = 7520/1000 = 7.52 ≈ 7.5 mL
Answer
V = 7.5 mL
32.Pediatric & critical-care dosing
Answer: R = 45 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.
12·60 = 720 mcg/h
Pump rate
R = 720/16 = 45 mL/h
Answer
R = 45 mL/h
33.IV fluids & fluid balance
Answer: U = 1.04 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
275 + 200 + 300 + 275 = 1050 mL
Per kilogram per hour
U = 1050/(84·12) = 1.042 ≈ 1.04 mL/kg/h
Answer
U = 1.04 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 10 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
1000 − 200 = 800 mL
Time
t = 800/80 = 10 h
Answer
t = 10 h
That is about 10 h 00 min, so the bag runs out at about 07:00.
35.Clinical assessment scores
Answer: M = 6
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 = 15 − 4 − 5 = 6
M6: obeys commands
Answer
M = 6
36.Clinical assessment scores
Answer: low
APGAR score: five signs, each scored 0, 1 or 2, checked at 1 and 5 minutes after birth. Appearance (colour): blue or pale 0, pink body with blue extremities 1, pink all over 2. Pulse: absent 0, below 100/min 1, 100/min or more 2. Grimace (reflex irritability): none 0, grimace 1, cry, cough or sneeze 2. Activity (tone): limp 0, some flexion 1, active movement 2. Respiration: absent 0, slow or irregular with a weak cry 1, good with a strong cry 2. A total of 7–10 is reassuring, 4–6 moderately abnormal and 0–3 low.
Score each sign
Appearance: blue or pale skin all over → 0
Pulse: 0 → 0
Grimace: no response to stimulation → 0
Activity: limp limbs with no muscle tone → 0
Respiration: no breathing → 0
Add
APGAR = 0 + 0 + 0 + 0 + 0 = 0
Interpretation
0 → low
Answer
low
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 25.3 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
|53 − 40| = 13 mmHg → 1.3 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·1.3 = 25.3 mmol/L
Answer
HCO₃⁻ = 25.3 mmol/L
38.Arterial blood gas interpretation
Answer: pure high-gap 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.
Anion gap
AG = 145 − (107 + 15) = 23
Delta ratio
(23 − 12)/(24 − 15) = 1.222
pure high-gap acidosis
Answer
pure high-gap acidosis
39.ECG rhythm strip interpretation
Answer: QTc = 0.42 s
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 = 10.5 × 0.04 = 0.42 s
RR = 25 × 0.04 = 1.00 s
Bazett’s formula
QTc = 0.42/√1.00 = 0.42/1 = 0.42 s
Answer
QTc = 0.42 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (420 ms)
40.ECG rhythm strip interpretation
Answer: asystole
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
Five steps
1. Rate: no countable ventricular rate.
2. Rhythm: none; an almost flat line.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: no QRS complexes.
Interpretation
asystole
Answer
asystole
A flat line is always checked: look at the patient, the leads and the gain, and view a second lead, because a loose electrode or fine VF can look like asystole.
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