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
Using the AVPU scale, a patient who opens their eyes and groans only when the nurse squeezes their shoulder is scored as:
AU
BV
CP
DA
2.Nursing fundamentalsHard
A colleague asks the nurse to countersign the controlled drug register for a dose the nurse did not see being prepared or given. What should the nurse do?
ASign, but only if the colleague is senior
BRefuse, as they can only sign for what they have witnessed
CSign it later, at the end of the shift, once the colleague explains
DSign, as the colleague is trustworthy
3.Infection control & patient safetyMedium
A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?
AVisit only if the cold started more than a day ago
BVisit but avoid touching the patient’s bed
CPostpone the visit until the visitor is well
DVisit as usual after washing the hands
4.Infection control & patient safetyHard
A nurse is about to give IV morphine. The patient’s respiratory rate is 9/min and they are very drowsy. What should the nurse do?
AWithhold the dose, assess the patient and inform the prescriber
BGive the dose because pain was reported earlier
CGive the dose and recheck the respiratory rate tomorrow
DGive half the dose
5.Prioritization & delegationMedium
An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?
AApply wrist restraints for the rest of the night
BGive a sedative from the as-needed list without first assessing the patient
CRaise all four bed rails so the patient cannot climb out
DCheck for pain, thirst or a full bladder, and offer toileting
6.Prioritization & delegationHard
A patient with diabetes is sweaty and confused, and no glucose meter is available. The patient can swallow. What should the nurse do?
AAsk the patient to lie down and sleep it off
BGive a dose of rapid-acting insulin in case the glucose is high
CTreat for hypoglycemia with fast-acting oral carbohydrate
DWithhold all food and fluids until a meter is found
7.Clinical nursingMedium
An arterial blood gas shows a low pH, a high PaCO2 and a normal bicarbonate. What does this show?
AMetabolic acidosis
BMetabolic alkalosis
CRespiratory alkalosis
DRespiratory acidosis
8.Clinical nursingHard
A hypotensive postoperative patient is given a fluid bolus. Which findings suggest a good response?
AThe heart rate rises further and the patient becomes more confused
BThe heart rate falls, blood pressure rises and urine output improves
CThe respiratory rate rises and new lung crackles appear
DThe capillary refill time becomes longer
9.Lab values & electrolytesMedium
In the US, when is a pregnant woman without known risk factors usually screened for gestational diabetes?
AAt about 38–40 weeks of pregnancy
BOnly after the baby is born
CAt about 24–28 weeks of pregnancy
DAt about 6–8 weeks of pregnancy
10.Lab values & electrolytesHard
A patient on warfarin with an INR of 3.6 fell and hit their head an hour ago. They now report a worsening headache and drowsiness. What is the priority?
AEncourage rest in a dark room to settle the pain
BReport urgently for imaging and possible reversal
CGive acetaminophen (paracetamol) and recheck the INR tomorrow
DHold warfarin for one dose and observe at home
11.PharmacologyMedium
A patient takes cholestyramine. How should other oral medicines be timed?
ATake them 1 hour before or several hours after cholestyramine
BTiming does not matter, as cholestyramine is not absorbed
CMix them into the cholestyramine drink so they are taken together
DTake them all at the same time as cholestyramine
12.PharmacologyHard
A postoperative patient using morphine PCA is very drowsy, hard to rouse and has a respiratory rate of 7 per minute. What should the nurse do first?
AEncourage the patient to press the button only when awake and in pain
BLet the patient sleep and recheck in one hour
CStop the PCA, try to rouse the patient and give naloxone as per protocol
DReduce the PCA dose and leave the pump running
13.Med-surg: cardiovascular & respiratoryMedium
A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?
AThe reading will be falsely low
BThe reading will be falsely high
COnly the pulse rate will be affected
DThe reading will be accurate but slower
14.Med-surg: cardiovascular & respiratoryHard
A patient on an unfractionated heparin infusion has a nosebleed that will not stop, and the aPTT is far above the target range. What is the most appropriate action?
AIncrease the infusion, as the aPTT will settle
BGive vitamin K and continue the infusion at a slightly lower rate
CStop the infusion, inform the prescriber and anticipate protamine
DContinue the infusion at the same rate and pack the nose firmly
15.Med-surg: neuro, endocrine & renalMedium
A patient's fistula starts to bleed at home after the needles were removed. What should they do first?
AApply a tight tourniquet above the fistula
BRaise the arm and let it bleed freely
CPress firmly on the site with clean gauze
DWait for the next dialysis session
16.Med-surg: neuro, endocrine & renalHard
A patient taking lithium has polyuria and thirst, and the urine does not concentrate after desmopressin. What is the most likely cause?
ANephrogenic DI caused by lithium
BCranial DI after a head injury
CNewly developed type 1 diabetes
DSIADH caused by lithium
17.Med-surg: GI, perioperative & oncologyMedium
Why may modified-release or enteric-coated tablets not work well for a patient with an ileostomy?
APatients with an ileostomy cannot take any oral medicines
BThe stoma absorbs the drug far too quickly into the blood
CFast transit means it may pass before releasing the drug
DThe ileostomy enzymes destroy every type of oral medicine
18.Med-surg: GI, perioperative & oncologyHard
A worker has a hydrofluoric acid burn on the hand and severe pain. After irrigation with water, which specific treatment is commonly applied?
ACalcium gluconate gel
BSodium bicarbonate paste
CSilver sulfadiazine cream
DIce cubes wrapped in a cloth
19.Maternity & obstetric nursingMedium
Which statement describes the "4 Ts" causes of postpartum haemorrhage?
ATone, trauma, tissue and thrombin
BTrauma, tension, temperature and thrombosis
CTemperature, tachycardia, tears and time
DTone, tachycardia, transfusion and tissue
20.Maternity & obstetric nursingHard
A pregnant woman tests positive for hepatitis B surface antigen. What should the nurse expect for the newborn?
AFormula feeding only, because breastfeeding is contraindicated
BA caesarean birth to prevent all transmission
CHepatitis B vaccine within hours of birth, often with immunoglobulin
DNo treatment until the baby is 6 months old
21.Pediatric nursingMedium
How should anti-sickness medicine be given to a child receiving chemotherapy that often causes vomiting?
AOnly after the child has already vomited at least twice
BOnly if the child asks for it
CBefore the chemotherapy starts and then regularly
DOnly at night, when the child is asleep
22.Pediatric nursingHard
Five minutes after IM adrenaline for anaphylaxis, a child is still wheezing and has a low blood pressure. What should the nurse do?
AGive a further dose of IM adrenaline as per protocol and call for advanced help
BSit the child up and walk her around to raise the blood pressure
CGive an oral antihistamine and a steroid instead of more adrenaline
DWait 30 minutes for the first dose of adrenaline to take its full effect
23.Mental health nursingMedium
A man taking risperidone reports breast enlargement and his partner says he has lost interest in sex. Which effect is the most likely cause?
ALow blood sodium
BLow thyroid hormone
CRaised prolactin
DRaised blood calcium
24.Mental health nursingHard
A patient in a manic episode is interrupting other patients and becoming louder in the day room. What is the most appropriate nursing action?
ATurn up the music to distract the group
BArgue with the patient about the behaviour in front of everyone until the patient agrees to stop
CCalmly guide the patient to a quieter area with less stimulation and set clear, simple limits
DEncourage a competitive group game to use up energy
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 101.7 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
101.7 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 1½ tsp of an oral suspension every 8 hours for 10 days. Using 1 tsp = 5 mL, how many mL V are needed for the whole course?
1½ tspevery 8 hours10 days1 tsp = 5 mL
V = mL
27.Dosage calculationsMedium
A child weighing 16 kg is prescribed 2.5 mg/kg of a drug. The stock solution contains 40 mg/mL. Draw up the dose: what volume V do you give?
16 kg2.5 mg/kg40 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 445 micrograms. The ampoule contains 0.5 mg/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
445 mcg0.5 mg/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 30 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 8 hours?
30 gtt/min15 gtt/mL8 h
V = mL
30.IV infusion ratesHard
A bag contains 500 mg of a drug in 250 mL and runs at 30 mL/h. How many milligrams per hour D does the patient receive?
500 mg/250 mL30 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 12 500 units of heparin in 250 mL. The order is 14 units/kg/h for a patient who weighs 90 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
12 500 units/250 mL14 units/kg/h90 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dopamine infusion of 800 mg in 500 mL runs at 22 mL/h. The patient weighs 54 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
800 mg/500 mL22 mL/h54 kg
D = mcg/kg/min
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 97 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 infusion starts at 07:00 at 125 mL/h. After 4 hours the rate is changed to 60 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL125 mL/h · 4 h60 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: no; ambulatory aid: holds on to furniture; IV therapy or saline lock: no; gait: weak; mental status: overestimates or forgets limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 92 kg and is 178 cm tall. Calculate the BMI and click the WHO weight category.
92 kg178 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 58 mmHg (7.7 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⁻.
A practice gas shows a respiratory acidosis: pH 7.19, PaCO₂ 74 mmHg (9.9 kPa), HCO₃⁻ 27 mmol/L. Use the rules ‘HCO₃⁻ rises 1 mmol/L per 10 mmHg (acute) or 3.5 mmol/L per 10 mmHg (chronic)’ to classify it. Click your answer.
pH 7.19PaCO₂ 74 mmHg (9.9 kPa)HCO₃⁻ 27 mmol/L
1acute
2chronic
3acute on chronic
39.ECG rhythm strip interpretationMedium
Measure the QT interval on this lead II strip, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QT = 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: C · P
Why this is the answer
AVPU stands for Alert, responds to Voice, responds to Pain, Unresponsive. A response only to a painful stimulus is "P", a serious sign that needs urgent review.
Answer
C · P
2.Nursing fundamentals
Answer: B · Refuse, as they can only sign for what they have witnessed
Why this is the answer
Countersigning means confirming that you witnessed the check and administration. Signing for something you did not see is dishonest and removes an important safety check.
Answer
B · Refuse, as they can only sign for what they have witnessed
3.Infection control & patient safety
Answer: C · Postpone the visit until the visitor is well
Why this is the answer
Patients with severe neutropenia cannot fight infections well. People with respiratory or other infections should not visit until they are well; other visitors perform hand hygiene.
Answer
C · Postpone the visit until the visitor is well
4.Infection control & patient safety
Answer: A · Withhold the dose, assess the patient and inform the prescriber
Why this is the answer
Slow breathing and sedation suggest opioid excess, so another dose could cause respiratory arrest. The nurse holds the dose, stimulates and assesses the patient, prepares naloxone per order and escalates.
Answer
A · Withhold the dose, assess the patient and inform the prescriber
5.Prioritization & delegation
Answer: D · Check for pain, thirst or a full bladder, and offer toileting
Why this is the answer
Patients with dementia may not be able to say what they need. Checking for pain, thirst or the need to void often relieves restlessness; restraints, full bed rails and sedation have risks and are not first choices.
Answer
D · Check for pain, thirst or a full bladder, and offer toileting
6.Prioritization & delegation
Answer: C · Treat for hypoglycemia with fast-acting oral carbohydrate
Why this is the answer
When in doubt, treat as hypoglycemia. A little sugar will not harm a patient with high glucose, but untreated hypoglycemia can cause brain injury within minutes, and insulin could be fatal.
Answer
C · Treat for hypoglycemia with fast-acting oral carbohydrate
7.Clinical nursing
Answer: D · Respiratory acidosis
Why this is the answer
A raised PaCO2 with a low pH means the lungs are not removing enough CO2, for example from hypoventilation. A normal bicarbonate suggests it is acute.
Answer
D · Respiratory acidosis
8.Clinical nursing
Answer: B · The heart rate falls, blood pressure rises and urine output improves
Why this is the answer
After a fluid challenge, a falling heart rate, rising blood pressure, better capillary refill, improving consciousness and urine output suggest fluid responsiveness. New crackles or breathlessness suggest fluid overload.
Answer
B · The heart rate falls, blood pressure rises and urine output improves
9.Lab values & electrolytes
Answer: C · 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.Checked against:Glucose screening tests during pregnancy · MedlinePlus (NIH) (2026); Gestational diabetes · MedlinePlus (NIH) (2026)
Answer
C · At about 24–28 weeks of pregnancy
10.Lab values & electrolytes
Answer: B · Report urgently for imaging and possible reversal
Why this is the answer
A head injury in an anticoagulated patient, with worsening headache and drowsiness, suggests intracranial bleeding. The provider is told at once, neurological checks are done often, urgent imaging is arranged, and warfarin reversal (vitamin K and a prothrombin complex concentrate) may be prescribed.Checked against:Taking warfarin (Coumadin, Jantoven) - what to ask your doctor · MedlinePlus (NIH) (2025); Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024)
Answer
B · Report urgently for imaging and possible reversal
11.Pharmacology
Answer: A · Take them 1 hour before or several hours after cholestyramine
Why this is the answer
Bile acid sequestrants bind many drugs, such as warfarin, digoxin and levothyroxine, as well as fat-soluble vitamins. Other drugs are taken about 1 hour before or 4–6 hours after it.
Answer
A · Take them 1 hour before or several hours after cholestyramine
12.Pharmacology
Answer: C · Stop the PCA, try to rouse the patient and give naloxone as per protocol
Why this is the answer
Excessive sedation and a low respiratory rate signal opioid-induced respiratory depression. The opioid is stopped, the patient is stimulated and supported with oxygen, naloxone is given as per protocol and help is called.
Answer
C · Stop the PCA, try to rouse the patient and give naloxone as per protocol
13.Med-surg: cardiovascular & respiratory
Answer: B · The reading will be falsely high
Why this is the answer
A cuff that is too small needs a higher pressure to compress the brachial artery, giving a falsely high reading. A cuff that is too large can give a falsely low reading. The bladder should encircle most of the arm, so cuff size is chosen by arm circumference.
Answer
B · The reading will be falsely high
14.Med-surg: cardiovascular & respiratory
Answer: C · Stop the infusion, inform the prescriber and anticipate protamine
Why this is the answer
With bleeding and a high aPTT, the heparin infusion is stopped at once and the prescriber informed. Because heparin's effect wears off within hours, stopping is often enough, but protamine sulfate can reverse it. Vitamin K reverses warfarin, not heparin.
Answer
C · Stop the infusion, inform the prescriber and anticipate protamine
15.Med-surg: neuro, endocrine & renal
Answer: C · Press firmly on the site with clean gauze
Why this is the answer
Firm, direct pressure with clean gauze or a dressing is applied to the site. A tourniquet could clot the fistula. If bleeding does not stop, the patient calls emergency services, because fistula bleeding can be heavy.
Answer
C · Press firmly on the site with clean gauze
16.Med-surg: neuro, endocrine & renal
Answer: A · Nephrogenic DI caused by lithium
Why this is the answer
Lithium is a common cause of nephrogenic DI, in which the collecting ducts do not respond to ADH, so desmopressin has little effect. Management includes specialist review of the lithium, access to water and monitoring of sodium and lithium levels.
Answer
A · Nephrogenic DI caused by lithium
17.Med-surg: GI, perioperative & oncology
Answer: C · Fast transit means it may pass before releasing the drug
Why this is the answer
Without the colon, gut transit is faster, so slow-release or coated preparations may be poorly absorbed. Tablet remnants may appear in the pouch. A pharmacist can suggest alternative formulations.
Answer
C · Fast transit means it may pass before releasing the drug
18.Med-surg: GI, perioperative & oncology
Answer: A · Calcium gluconate gel
Why this is the answer
Hydrofluoric acid penetrates deeply and binds calcium and magnesium, causing severe pain and possible life-threatening hypocalcaemia. Calcium gluconate gel binds fluoride; serum calcium and heart rhythm are monitored in larger exposures.
Answer
A · Calcium gluconate gel
19.Maternity & obstetric nursing
Answer: A · Tone, trauma, tissue and thrombin
Why this is the answer
The 4 Ts are tone (atony), trauma (tears, haematomas, rupture), tissue (retained placenta or clots) and thrombin (clotting disorders). Tone is the most common cause.
Answer
A · Tone, trauma, tissue and thrombin
20.Maternity & obstetric nursing
Answer: C · Hepatitis B vaccine within hours of birth, often with immunoglobulin
Why this is the answer
Babies of HBsAg-positive mothers get a first dose of hepatitis B vaccine soon after birth. In the US, all of them also receive hepatitis B immunoglobulin (HBIG) within 12 hours; in the UK, the vaccine is given within 24 hours and HBIG is added when the mother is highly infectious (for example HBeAg-positive or with a high viral load). Breastfeeding is not contraindicated, and the vaccine series is completed later.
Answer
C · Hepatitis B vaccine within hours of birth, often with immunoglobulin
21.Pediatric nursing
Answer: C · Before the chemotherapy starts and then regularly
Why this is the answer
Antiemetics work best when given before chemotherapy and on a regular schedule, not only after vomiting begins. Uncontrolled vomiting can also cause anticipatory nausea with later treatments.
Answer
C · Before the chemotherapy starts and then regularly
22.Pediatric nursing
Answer: A · Give a further dose of IM adrenaline as per protocol and call for advanced help
Why this is the answer
IM adrenaline can be repeated after about 5 minutes if signs persist. Help is called, the child lies flat (with legs raised if tolerated, or sitting if breathing is difficult), and oxygen and IV fluids are given. Standing or walking can cause collapse.
Answer
A · Give a further dose of IM adrenaline as per protocol and call for advanced help
23.Mental health nursing
Answer: C · Raised prolactin
Why this is the answer
Blocking dopamine in the tuberoinfundibular pathway raises prolactin. This can cause gynaecomastia, galactorrhoea, menstrual problems and sexual dysfunction; risperidone and first-generation antipsychotics commonly cause it.
Answer
C · Raised prolactin
24.Mental health nursing
Answer: C · Calmly guide the patient to a quieter area with less stimulation and set clear, simple limits
Why this is the answer
Patients with mania benefit from a calm, low-stimulus environment, firm and consistent limits and simple, non-competitive activities.
Answer
C · Calmly guide the patient to a quieter area with less stimulation and set clear, simple limits
25.Nursing math & unit conversions
Answer: T = 38.7 °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
101.7 − 32 = 69.7
Multiply by 5/9
T = 69.7·5/9 = 38.72 ≈ 38.7 °C
Answer
T = 38.7 °C
26.Nursing math & unit conversions
Answer: V = 225 mL
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.
Volume per dose
1½ tsp = 1.5·5 = 7.5 mL
Whole course
V = 7.5 mL × 3/day × 10 = 225 mL
Answer
V = 225 mL
27.Dosage calculations
Answer: V = 1 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.
Dose from body weight
D = 2.5·16 = 40 mg
Volume
V = 40/40 = 1 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 1 mL
28.Dosage calculations
Answer: V = 0.89 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
0.5 mg/mL = 500 mcg/mL
Volume
V = 445/500 = 0.89 mL
Answer
V = 0.89 mL
29.IV infusion rates
Answer: V = 960 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
30·60/15 = 120 mL/h
Volume
V = 120·8 = 960 mL
Answer
V = 960 mL
30.IV infusion rates
Answer: D = 60 mg/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Concentration
500/250 = 2 mg/mL
Dose rate
D = 2·30 = 60 mg/h
Answer
D = 60 mg/h
31.Pediatric & critical-care dosing
Answer: R = 25.2 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
14·90 = 1 260 units/h
Concentration
12 500/250 = 50 units/mL
Pump rate
R = 1260/50 = 25.2 mL/h
Answer
R = 25.2 mL/h
32.Pediatric & critical-care dosing
Answer: D = 10.9 mcg/kg/min
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
800 000/500 = 1600 mcg/mL
Micrograms per minute
22·1600 = 35200 mcg/h
35200/60 = 586.7 mcg/min
Per kilogram
D = 586.7/54 = 10.86 ≈ 10.9 mcg/kg/min
Answer
D = 10.9 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 1.18 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
325 + 275 + 325 + 450 = 1375 mL
Per kilogram per hour
U = 1375/(97·12) = 1.181 ≈ 1.18 mL/kg/h
Answer
U = 1.18 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 12.3 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.
First part
125·4 = 500 mL
1000 − 500 = 500 mL left
Second part
500/60 = 8.333 h
Total time
t = 4 + 8.333 = 12.33 ≈ 12.3 h
Answer
t = 12.3 h
That is about 12 h 20 min, so the bag runs out at about 19:20.
35.Clinical assessment scores
Answer: MFS = 55
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: no → 0
secondary diagnosis: no → 0
ambulatory aid: holds on to furniture → 30
IV therapy or saline lock: no → 0
gait: weak → 10
mental status: overestimates or forgets limits → 15
Add
Morse total = 0 + 0 + 30 + 0 + 10 + 15 = 55
Answer
MFS = 55
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 = 92/1.78² = 29.04
Category
overweight
Answer
overweight
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 30.3 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
|58 − 40| = 18 mmHg → 1.8 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·1.8 = 30.3 mmol/L
Answer
HCO₃⁻ = 30.3 mmol/L
38.Arterial blood gas interpretation
Answer: acute
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected HCO₃⁻
acute: 24 + 1·3.4 = 27.4 mmol/L
chronic: 24 + 3.5·3.4 = 35.9 mmol/L
Compare
measured: 27 mmol/L → acute
Answer
acute
39.ECG rhythm strip interpretation
Answer: QT = 0.36 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
9 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 9 × 0.04 s = 0.36 s
Answer
QT = 0.36 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 0.60 s).
40.ECG rhythm strip interpretation
Answer: ventricular rate = 38 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 = 18 small boxes = 0.72 s → 1500 ÷ 18 = 83.33 ≈ 83 per minute
Ventricular rate
R–R = 40 small boxes = 1.60 s → 1500 ÷ 40 = 37.5 ≈ 38 per minute
Answer
ventricular rate = 38 bpm
Answer
ventricular rate = 38 bpm
Third-degree block with a wide-complex ventricular escape (usually 20–40 per minute).
This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.