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 orthostatic (postural) hypotension?
AA difference of more than 10 mmHg in blood pressure between the two arms
BA fall in blood pressure on standing up, often causing dizziness
CLow blood pressure only during sleep
DHigh blood pressure when lying down
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?
AComplete an incident report
BTalk to the healthcare assistant about reporting
CRepeat the observations at the next routine time
DAssess the patient straight away
3.Infection control & patient safetyMedium
While a sterile field is being prepared, the nurse turns away from it to answer a question. What is correct?
AThe field is considered contaminated and must be set up again
BThe field is still sterile because nobody touched it in the meantime
CThe field can be used if it is covered afterwards
DOnly the items nearest the nurse need to be replaced
4.Infection control & patient safetyHard
A nurse working with a patient on contact precautions realizes the gown has a tear at the sleeve. What should the nurse do?
APut a second gown on top of the torn one
BMove away from the patient, remove the PPE safely at the doorway, clean hands and re-gown
CCover the tear with a strip of tape and carry on
DContinue working, since the tear is small and only on the sleeve
5.Prioritization & delegationMedium
A registered nurse tells a nursing assistant, “Check on the patient in room 12.” Which right of delegation is missing?
ARight directions and communication
BRight task for the setting
CRight person for the task
DRight circumstance
6.Prioritization & delegationHard
A patient arrives at the emergency department with a plan to end their life, but has normal vital signs. Which ESI level fits best?
ALevel 2
BLevel 5
CLevel 4
DLevel 1
7.Clinical nursingMedium
A patient's seizure has lasted more than five minutes. What does this mean?
AIt should be treated as status epilepticus and emergency medication given
BPlace something in the mouth to prevent tongue biting
CRestrain the limbs to stop the movements
DIt is normal and needs no treatment
8.Clinical nursingHard
Which patient should a ward nurse assess first at the start of a shift?
AA patient asking for a laxative
BA patient awaiting discharge with stable observations
CA patient with new-onset confusion and a respiratory rate of 28/min
DA patient with chronic back pain scored 4/10
9.Lab values & electrolytesMedium
A patient who has been vomiting for two days has a BUN of 32 mg/dL (urea 11.4 mmol/L) and a normal creatinine. What is the most likely cause?
AOverhydration
BLow-protein diet
CDehydration
DLiver failure
10.Lab values & electrolytesHard
A patient with severe vomiting has a potassium of 3.0 mEq/L, a chloride of 88 mEq/L and a high bicarbonate. What pattern does this show?
AHigh potassium with metabolic acidosis caused by dehydration
BLoss of stomach acid: low potassium and chloride, metabolic alkalosis
CNormal results that need no follow-up
DDiabetic ketoacidosis with a high anion gap
11.PharmacologyMedium
Which adverse effect is typical of metoclopramide, especially in young people?
ADry cough
BSevere constipation
CLow blood glucose
DExtrapyramidal movement disorders such as acute dystonia
12.PharmacologyHard
A woman with epilepsy who takes an antiepileptic drug plans to become pregnant. Which advice is standard?
AAvoid folic acid because it lowers drug levels
BStop all antiepileptic drugs straight away as soon as she stops contraception
CTake folic acid before conception and seek specialist review of her medication
DNo change is needed, as antiepileptics carry no risk in pregnancy
13.Med-surg: cardiovascular & respiratoryMedium
A patient has a heart rate of 36/min with hypotension and dizziness. Which drug is usually the first choice?
AOral bisoprolol
BIntravenous adenosine
CIntravenous atropine
DIntravenous amiodarone
14.Med-surg: cardiovascular & respiratoryHard
A patient with heart failure has gained 2.5 kg in three days, has new crackles at both bases and now sleeps on four pillows. BP 138/84 mmHg, SpO₂ 93% on air. What is the priority?
ALay the patient flat to rest the heart and lower demand
BEncourage extra oral fluids to protect the kidneys
CSit the patient up, assess fully and report the fluid overload
DRecord the weight and check it again at the end of the next week
15.Med-surg: neuro, endocrine & renalMedium
Which complication of haemodialysis causes headache, nausea, restlessness and sometimes seizures, especially in the first sessions?
ADialysis disequilibrium syndrome
BBacterial peritonitis
CDialysate hypoglycaemia
DVenous air embolism through the lines
16.Med-surg: neuro, endocrine & renalHard
A patient on long-term high-dose prednisolone is three days after bowel surgery. They report only mild abdominal pain, but the heart rate has risen to 115/min and the temperature is 37.4 °C. Why should the nurse be especially concerned?
AThe mild pain shows that the bowel is healing as expected
BSteroids can mask fever, pain and peritonism, hiding complications
CSteroids protect against infection, so sepsis is very unlikely
DSteroids cause tachycardia in all patients, so no action is needed
17.Med-surg: GI, perioperative & oncologyMedium
Which complication is more typical of Crohn's disease than of ulcerative colitis?
ADisease that is cured by removing the colon
BFistulas between the bowel and other organs
CInflammation limited to the rectal lining
DBleeding only from the rectum
18.Med-surg: GI, perioperative & oncologyHard
A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?
ACall for urgent anaesthetic help, as the airway is swelling
BLay the patient flat to help them sleep
CEncourage the patient to rest the voice and reassess tomorrow
DGive a warm drink to soothe the throat
19.Maternity & obstetric nursingMedium
Which complication should the nurse monitor for after an epidural is started in labour?
AIncreased bladder sensation
BMaternal hyperglycaemia
CMaternal hypotension
DMaternal hypertension
20.Maternity & obstetric nursingHard
Which statement by a woman being discharged after birth shows a need for further teaching?
A"I should report a painful, swollen calf straight away."
B"I should change my pads regularly and wash my hands."
C"I should call if my bleeding gets heavier or smells bad."
D"I can use tampons for the bleeding as soon as I get home."
21.Pediatric nursingMedium
Which finding is an early sign of shock in a child?
AA fast heart rate with a prolonged capillary refill
BA warm, flushed child with a strong, bounding pulse
CSlow, deep breathing with a normal heart rate
DLow blood pressure with a slow heart rate and pauses in breathing
22.Pediatric nursingHard
Which phone call should the nurse return first?
AA parent of a 3-year-old with a runny nose and a mild cough for 2 days
BA parent of a 5-month-old who has had no wet nappy for 12 hours and is very sleepy
CA parent of a 7-year-old with a faint rash 3 days into antibiotics, breathing normally
DA parent asking when the next routine vaccines are due
23.Mental health nursingMedium
Which group of findings suggests neuroleptic malignant syndrome?
AWeight gain and raised blood glucose
BHyperreflexia, clonus, diarrhoea, dilated pupils and agitation within hours of a new serotonergic drug
CFine tremor and increased thirst
DHigh fever, severe "lead-pipe" muscle rigidity, confusion, unstable blood pressure and a raised CK
24.Mental health nursingHard
The parent of a child recently diagnosed with autism asks, "Did his vaccines cause this?" What is the most accurate response?
A"Large studies have found no link between vaccines and autism."
B"Yes, the MMR vaccine is a proven cause of autism."
C"Autism is caused by cold and distant parenting styles in early childhood."
D"We don't know, so it is best to stop all of his other vaccines."
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 39.2 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
39.2 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 19:35 and finishes at 07:30 the next morning (24-hour clock). How many hours t did it run? Give the answer in hours as a decimal, rounded to two decimal places.
19:3507:30
t = h
27.Dosage calculationsMedium
A child weighing 20 kg is prescribed 2.5 mg/kg of a drug. The stock solution contains 25 mg/mL. Draw up the dose: what volume V do you give?
20 kg2.5 mg/kg25 mg/mL
V = mL
28.Dosage calculationsHard
A patient is 132 cm tall and weighs 35 kg. The prescription is 60 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
132 cm35 kg60 mg/m²
D = mg
29.IV infusion ratesMedium
A drip runs at 20 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 3 hours?
20 gtt/min15 gtt/mL3 h
V = mL
30.IV infusion ratesHard
A bag contains 500 mg of a drug in 50 mL and runs at 15 mL/h. How many milligrams per hour D does the patient receive?
500 mg/50 mL15 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 12 500 units of heparin in 250 mL. The order is 20 units/kg/h for a patient who weighs 78 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
12 500 units/250 mL20 units/kg/h78 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dopamine infusion of 400 mg in 250 mL runs at 40 mL/h. The patient weighs 57 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
400 mg/250 mL40 mL/h57 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 IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 80 mL/h. At 14:30, 200 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL200 mL infused80 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: completely limited; moisture: occasionally moist; activity: walks occasionally; mobility: slightly limited; nutrition: adequate; friction and shear: problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). At 1 minute after birth, a practice newborn has a pink body with blue hands and feet, a heart rate of 165/min, a cry, cough or sneeze when stimulated, active movement and slow, irregular breathing with a weak cry. Score the APGAR and click how the score is interpreted.
1reassuring
2moderately abnormal
3low
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 80 mmHg (10.7 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⁻.
At sea level, a practice gas taken on 28% oxygen shows PaO₂ 75 mmHg (10.0 kPa) and PaCO₂ 35 mmHg (4.7 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
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
Interpret this lead II strip. Which interpretation can you defend from this single 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
12:1 AV block (type undetermined)
2third-degree (complete) AV block
3second-degree AV block type II
4second-degree AV block type I (Wenckebach)
3Solutions
1.Nursing fundamentals
Answer: B · A fall in blood pressure on standing up, often causing dizziness
Why this is the answer
Orthostatic hypotension is a drop in blood pressure when moving to an upright position. It is common in older people and with some medicines and increases fall risk.
Answer
B · A fall in blood pressure on standing up, often causing dizziness
2.Nursing fundamentals
Answer: D · 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
D · Assess the patient straight away
3.Infection control & patient safety
Answer: A · The field is considered contaminated and must be set up again
Why this is the answer
A sterile field must be kept in view at all times. If sterility cannot be confirmed, the field is treated as contaminated. The rule is: if in doubt, consider it non-sterile.
Answer
A · The field is considered contaminated and must be set up again
4.Infection control & patient safety
Answer: B · Move away from the patient, remove the PPE safely at the doorway, clean hands and re-gown
Why this is the answer
Torn PPE allows contamination of skin and clothing. When it is safe, the nurse moves away from the patient, removes PPE in the correct order at the doorway or in the anteroom, cleans their hands and puts on new PPE.
Answer
B · Move away from the patient, remove the PPE safely at the doorway, clean hands and re-gown
5.Prioritization & delegation
Answer: A · Right directions and communication
Why this is the answer
“Check on” does not say what to measure, when, or which findings to report. A clear instruction would be, for example, “Measure his blood pressure and pulse at 10:00 and tell me at once if the systolic is below 100.”
Answer
A · Right directions and communication
6.Prioritization & delegation
Answer: A · Level 2
Why this is the answer
Active suicidal ideation with a plan is a high-risk situation, so the patient is ESI level 2. They need prompt evaluation and a safe environment with close observation.
Answer
A · Level 2
7.Clinical nursing
Answer: A · It should be treated as status epilepticus and emergency medication given
Why this is the answer
A seizure lasting five minutes or longer, or repeated seizures without recovery, is treated as status epilepticus. Protect from injury, give oxygen and give emergency anticonvulsants as prescribed.
Answer
A · It should be treated as status epilepticus and emergency medication given
8.Clinical nursing
Answer: C · A patient with new-onset confusion and a respiratory rate of 28/min
Why this is the answer
New confusion with tachypnoea suggests acute deterioration, such as sepsis or hypoxia. Patients with stable chronic problems can wait.
Answer
C · A patient with new-onset confusion and a respiratory rate of 28/min
9.Lab values & electrolytes
Answer: C · Dehydration
Why this is the answer
When the body is short of fluid, the kidneys reabsorb more urea, so the BUN rises out of proportion to creatinine (a BUN-to-creatinine ratio above 20:1). Liver failure and a low-protein diet lower the BUN.Checked against:BUN (Blood Urea Nitrogen) · MedlinePlus (NIH) (2024)
Answer
C · Dehydration
10.Lab values & electrolytes
Answer: B · Loss of stomach acid: low potassium and chloride, metabolic alkalosis
Why this is the answer
Vomiting removes hydrochloric acid, so chloride falls and bicarbonate rises (metabolic alkalosis). The kidneys then lose potassium. Replacement usually includes 0.9% sodium chloride with potassium as prescribed.Checked against:Alkalosis · StatPearls (NCBI Bookshelf) (2024)
Answer
B · Loss of stomach acid: low potassium and chloride, metabolic alkalosis
11.Pharmacology
Answer: D · Extrapyramidal movement disorders such as acute dystonia
Why this is the answer
Metoclopramide is a dopamine D2 antagonist. Blocking dopamine in the basal ganglia can cause dystonia and other extrapyramidal effects, more often in young adults.
Answer
D · Extrapyramidal movement disorders such as acute dystonia
12.Pharmacology
Answer: C · Take folic acid before conception and seek specialist review of her medication
Why this is the answer
Folic acid before and in early pregnancy reduces the risk of neural tube defects. Medication should be reviewed before conception, but drugs should not be stopped suddenly because uncontrolled seizures are also dangerous.
Answer
C · Take folic acid before conception and seek specialist review of her medication
13.Med-surg: cardiovascular & respiratory
Answer: C · Intravenous atropine
Why this is the answer
Atropine is an antimuscarinic that removes vagal tone and raises the heart rate. It is first-line for symptomatic bradycardia. If it fails, other options include a drug infusion or cardiac pacing. Adenosine, bisoprolol and amiodarone all slow conduction.
Answer
C · Intravenous atropine
14.Med-surg: cardiovascular & respiratory
Answer: C · Sit the patient up, assess fully and report the fluid overload
Why this is the answer
Rapid weight gain with crackles and orthopnoea indicates fluid overload and worsening heart failure. Sitting upright reduces venous return and eases breathing. The nurse completes an assessment (oxygen trend, fluid balance, oedema) and escalates so the prescriber can adjust diuretics. More fluid or lying flat would worsen congestion.
Answer
C · Sit the patient up, assess fully and report the fluid overload
15.Med-surg: neuro, endocrine & renal
Answer: A · Dialysis disequilibrium syndrome
Why this is the answer
Rapid removal of urea from the blood creates an osmotic gradient, so water moves into brain cells, causing cerebral oedema. It is prevented by shorter, gentler first sessions.
Answer
A · Dialysis disequilibrium syndrome
16.Med-surg: neuro, endocrine & renal
Answer: B · Steroids can mask fever, pain and peritonism, hiding complications
Why this is the answer
Long-term steroids blunt fever, pain and abdominal rigidity, so an anastomotic leak, abscess or perforation may present only with subtle signs such as tachycardia. The nurse should assess thoroughly and escalate early. These patients also need steroid cover around surgery to prevent adrenal crisis.
Answer
B · Steroids can mask fever, pain and peritonism, hiding complications
17.Med-surg: GI, perioperative & oncology
Answer: B · Fistulas between the bowel and other organs
Why this is the answer
Transmural inflammation in Crohn's disease can create fistulas, abscesses and strictures. Ulcerative colitis is mucosal, and removing the colon and rectum is curative.
Answer
B · Fistulas between the bowel and other organs
18.Med-surg: GI, perioperative & oncology
Answer: A · Call for urgent anaesthetic help, as the airway is swelling
Why this is the answer
Progressive hoarseness and stridor after a facial or inhalation burn mean the airway is narrowing. Early intubation by an experienced anaesthetist is needed before swelling makes it impossible. The patient is sat up and given oxygen.
Answer
A · Call for urgent anaesthetic help, as the airway is swelling
19.Maternity & obstetric nursing
Answer: C · Maternal hypotension
Why this is the answer
An epidural causes vasodilation, so blood pressure can fall, which reduces blood flow to the placenta. Blood pressure and the fetal heart rate are checked frequently, and bladder distension is common because sensation is reduced.
Answer
C · Maternal hypotension
20.Maternity & obstetric nursing
Answer: D · "I can use tampons for the bleeding as soon as I get home."
Why this is the answer
Tampons are avoided until lochia has stopped and the postnatal check is done, because they increase the risk of infection. The other statements are correct.
Answer
D · "I can use tampons for the bleeding as soon as I get home."
21.Pediatric nursing
Answer: A · A fast heart rate with a prolonged capillary refill
Why this is the answer
Children maintain their blood pressure until late in shock. Early signs include tachycardia, prolonged capillary refill, cool peripheries, reduced urine output and changes in behaviour.
Answer
A · A fast heart rate with a prolonged capillary refill
22.Pediatric nursing
Answer: B · A parent of a 5-month-old who has had no wet nappy for 12 hours and is very sleepy
Why this is the answer
No urine for 12 hours and lethargy in an infant suggest significant dehydration and possible shock, which needs urgent assessment. The other calls involve mild or non-urgent problems.
Answer
B · A parent of a 5-month-old who has had no wet nappy for 12 hours and is very sleepy
23.Mental health nursing
Answer: D · High fever, severe "lead-pipe" muscle rigidity, confusion, unstable blood pressure and a raised CK
Why this is the answer
NMS usually develops over days, with hyperthermia, rigidity, altered consciousness, autonomic instability and raised creatine kinase. The antipsychotic is stopped and urgent medical care is given.
Answer
D · High fever, severe "lead-pipe" muscle rigidity, confusion, unstable blood pressure and a raised CK
24.Mental health nursing
Answer: A · "Large studies have found no link between vaccines and autism."
Why this is the answer
Large, well-conducted studies have found no link between vaccines and autism, and the paper that first claimed a link was retracted. Autism is a neurodevelopmental condition with strong genetic contributions.
Answer
A · "Large studies have found no link between vaccines and autism."
25.Nursing math & unit conversions
Answer: T = 102.6 °F
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.
Multiply by 9/5
39.2·9/5 = 70.56
Add 32
T = 70.56 + 32 = 102.6 °F
Answer
T = 102.6 °F
26.Nursing math & unit conversions
Answer: t = 11.92 h
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
19:35 → 24:00 = 265 min
After midnight
00:00 → 07:30 = 450 min
Total
265 + 450 = 715 min
t = 715/60 = 11.92 h
Answer
t = 11.92 h
27.Dosage calculations
Answer: V = 2 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 = 2.5·20 = 50 mg
Volume
V = 50/25 = 2 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 2 mL
28.Dosage calculations
Answer: D = 67.97 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
Body surface area
BSA = √(132·35/3600) = √1.283 = 1.133 m²
Dose
D = 60·1.133 = 67.97 mg
Answer
D = 67.97 mg
29.IV infusion rates
Answer: V = 240 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
20·60/15 = 80 mL/h
Volume
V = 80·3 = 240 mL
Answer
V = 240 mL
30.IV infusion rates
Answer: D = 150 mg/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Concentration
500/50 = 10 mg/mL
Dose rate
D = 10·15 = 150 mg/h
Answer
D = 150 mg/h
31.Pediatric & critical-care dosing
Answer: R = 31.2 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
20·78 = 1 560 units/h
Concentration
12 500/250 = 50 units/mL
Pump rate
R = 1560/50 = 31.2 mL/h
Answer
R = 31.2 mL/h
32.Pediatric & critical-care dosing
Answer: D = 18.7 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
400 000/250 = 1600 mcg/mL
Micrograms per minute
40·1600 = 64000 mcg/h
64000/60 = 1067 mcg/min
Per kilogram
D = 1067/57 = 18.71 ≈ 18.7 mcg/kg/min
Answer
D = 18.7 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = 310 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total intake
oral: 240 + 200 = 440 mL
IV infusion: 100·12 = 1200 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1690 mL
Total output
450 + 400 + 450 + 80 = 1380 mL
Balance
B = 1690 − 1380 = 310 mL
Answer
B = 310 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 3.8 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
500 − 200 = 300 mL
Time
t = 300/80 = 3.75 ≈ 3.8 h
Answer
t = 3.8 h
That is about 3 h 45 min, so the bag runs out at about 18:15.
35.Clinical assessment scores
Answer: B = 14
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: completely limited → 1
moisture: occasionally moist → 3
activity: walks occasionally → 3
mobility: slightly limited → 3
nutrition: adequate → 3
friction and shear: problem → 1
Add
Braden total = 1 + 3 + 3 + 3 + 3 + 1 = 14
Answer
B = 14
36.Clinical assessment scores
Answer: reassuring
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: a pink body with blue hands and feet → 1
Pulse: 165/min → 2
Grimace: a cry, cough or sneeze when stimulated → 2
Activity: active movement → 2
Respiration: slow, irregular breathing with a weak cry → 1
Add
APGAR = 1 + 2 + 2 + 2 + 1 = 8
Interpretation
8 → reassuring
Answer
reassuring
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 38 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
|80 − 40| = 40 mmHg → 4 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·4 = 38 mmol/L
Answer
HCO₃⁻ = 38 mmol/L
38.Arterial blood gas interpretation
Answer: A–a gradient = 80.89 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
11.5 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 11.5 × 0.04 s = 0.46 s
Answer
QT = 0.46 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 0.96 s).
40.ECG rhythm strip interpretation
Answer: 2:1 AV block (type undetermined)
2:1 AV block: with two P waves for every QRS, no two conducted P waves follow each other, so you cannot see whether the PR would lengthen (type I) or stay constant (type II) before a non-conducted P wave. From one strip it is called a 2:1 AV block; a longer strip or a change in the conduction ratio decides the type. A narrow QRS makes type I more likely and a wide QRS type II, but neither proves it.
Five steps
1. Rate: R–R = 44 small boxes, 1500 ÷ 44 ≈ 34 per minute.
2. Rhythm: regular, every R–R is 1.76 s.
3. P waves: upright and regular (P–P 0.88 s, 68 per minute), two for every QRS.
4. PR interval: constant at 0.16 s in the conducted beats.
5. QRS: 0.12 s, wide (0.12 s or more).
Why the type stays open
Every second P wave is not conducted, so no two conducted beats follow each other and a lengthening PR could never show.
2:1 AV block (type undetermined)
Answer
2:1 AV block (type undetermined)
A narrow QRS makes type I more likely and a wide QRS type II, but only a longer strip or a change in the conduction ratio decides.
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