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
Which adverse effect is a particular risk with NSAIDs such as ibuprofen?
AStomach irritation and bleeding
BBreathing slowing down
CLow blood sugar
DSevere constipation that lasts for weeks
2.Nursing fundamentalsHard
A 70 kg postoperative patient with a catheter has passed 20 mL of urine per hour for the last three hours. What is the best interpretation?
APolyuria needing fluid restriction
BNormal output after surgery
CA blocked catheter, which can safely be left until the morning team reviews it
DOliguria that should be escalated, as it is below 0.5 mL/kg/h
3.Infection control & patient safetyMedium
Which type of white blood cell is most often raised in viral infections?
ANeutrophils
BEosinophils
CLymphocytes
DBasophils
4.Infection control & patient safetyHard
A patient on an anticoagulant falls and hits their head but says they feel fine. What should the nurse do?
ANotify the provider and start neurological observations, because a brain bleed may develop
BWait until the next day to see if a headache develops
CGive the next anticoagulant dose early to prevent clots from forming after the fall
DHelp the patient back to bed and do nothing more if they feel fine
5.Prioritization & delegationMedium
Which finding is unexpected and needs prompt follow-up?
AA patient on a heparin infusion has a new black, tarry stool
BA patient with known cirrhosis has yellow skin that has not changed
CA patient with long-standing COPD has a barrel-shaped chest
DA patient one day after laparoscopic gallbladder surgery has right shoulder pain
6.Prioritization & delegationHard
An older patient with heart failure is receiving a second unit of blood. She becomes breathless, with crackles in both lungs and a rising blood pressure. What is most likely happening?
AA mild allergic reaction with hives
BAn expected effect of the first unit
CHypoglycemia caused by the stored blood product
DTransfusion-associated circulatory overload
7.Clinical nursingMedium
Which blood result often rises in an upper GI bleed because blood is digested in the gut?
AGlucose
BUrea (blood urea nitrogen)
CCalcium
DSodium
8.Clinical nursingHard
An acutely ill patient without COPD is on 15 L/min oxygen, and their SpO2 is now 100% and stable. What should be done?
AIncrease the oxygen further to build up a reserve
BStop the oxygen and the saturation monitoring because the patient is now well
CKeep the oxygen at 15 L/min for at least a week to be on the safe side
DReduce the oxygen to keep the SpO2 within the prescribed target range
9.Lab values & electrolytesMedium
A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?
AStop the infusion and give protamine sulfate as quickly as possible
BContinue the same rate and recheck the aPTT in a few days
CSwitch the infusion to oral warfarin without a prescription
DAdjust the rate as the protocol directs and recheck as scheduled
10.Lab values & electrolytesHard
A patient on digoxin has a calcium of 12.1 mg/dL (3.0 mmol/L) and new nausea and a slow pulse. Why is the calcium result important?
AHigh calcium only matters if the potassium is also high
BHigh calcium blocks digoxin, so the drug stops working
CHigh calcium increases the risk of digoxin toxicity
DHigh calcium makes the kidneys clear digoxin faster
11.PharmacologyMedium
Apixaban and rivaroxaban are anticoagulants that directly inhibit:
AFactor Xa
BThe platelet P2Y12 receptor
CVitamin K epoxide reductase
DThrombin
12.PharmacologyHard
A patient with heart failure starts taking naproxen regularly for back pain. Why is this a concern?
ANSAIDs lower potassium, which makes digoxin and diuretics fail
BNSAIDs block the absorption of furosemide completely
CNSAIDs cause salt and water retention and can worsen heart failure
DNSAIDs increase heart contractility too much
13.Med-surg: cardiovascular & respiratoryMedium
Unless fluids are restricted, why are patients with pneumonia encouraged to drink plenty?
ATo flush the bacteria out through the urine
BTo prevent dehydration and keep secretions thinner
CTo lower the temperature by diluting the blood plasma
DTo make the cough completely stop
14.Med-surg: cardiovascular & respiratoryHard
A patient who started an ACE inhibitor yesterday develops swelling of the lips and tongue and a hoarse voice. What should the nurse do first?
AAssess the airway, call for urgent help and hold further doses
BGive the next dose early, as this will settle the swelling quickly
CApply ice to the lips and review again in the morning
DExplain that this is an expected, harmless side effect
15.Med-surg: neuro, endocrine & renalMedium
For which patient would the nurse question an order for pioglitazone?
AA patient with heart failure
BA patient with asthma
CA patient with hypothyroidism
DA patient with an allergy to latex
16.Med-surg: neuro, endocrine & renalHard
A patient with Parkinson's disease is nil by mouth after abdominal surgery. Their levodopa is due. What is the best action?
AOmit the dose until the patient can swallow again
BContact the prescriber or pharmacist about another route
CGive double the dose once eating restarts
DGive the tablets with a sip of water anyway
17.Med-surg: GI, perioperative & oncologyMedium
How should a patient with facial burns usually be positioned?
ALying face down on the pillow to protect the airway
BWith the head of the bed raised to reduce swelling
CIn any position that keeps the face covered
DLying flat with the head lower than the feet
18.Med-surg: GI, perioperative & oncologyHard
Why is folinic acid (leucovorin) given after high-dose methotrexate?
ATo prevent hair loss during treatment
BTo increase the anticancer effect on the tumour
CTo treat the patient's anaemia only
DTo rescue normal cells from methotrexate toxicity
19.Maternity & obstetric nursingMedium
Which newborn is at greatest risk of hypoglycaemia in the first hours after birth?
AA large baby of a mother with diabetes
BA term baby of average weight who is breastfeeding well
CA baby born by planned caesarean to a healthy mother
DA baby with an APGAR of 9 at 5 minutes
20.Maternity & obstetric nursingHard
A nurse is teaching a mother how to prevent shaken baby syndrome. Which statement shows a need for further teaching?
A"If I get too frustrated, I will put him in his cot and step away for a few minutes."
B"I can call someone to help when I feel overwhelmed."
C"If I feel very angry, it is fine to shake him a little to stop the crying."
D"Crying often increases in the first weeks, and that can be normal."
21.Pediatric nursingMedium
Which is a true contraindication to a further dose of the same vaccine?
ARedness and soreness at the injection site after a previous dose
BA family history of allergies
CAnaphylaxis after a previous dose of that vaccine
DA low-grade fever after a previous dose
22.Pediatric nursingHard
A 7-year-old has a high fever, refuses to bear weight and has a warm, very tender area over the lower tibia. Which plan is most likely?
ABlood cultures and prompt IV antibiotics for possible osteomyelitis
BA plaster cast and discharge home the same day
CMassage and physiotherapy to loosen the muscle
DRest, ice and an elastic bandage for a sprained ankle, with review in a week
23.Mental health nursingMedium
What should a patient taking disulfiram be taught?
AAvoid all alcohol, including hidden sources such as some mouthwashes and sauces
BSmall amounts of beer are safe
CIt cures alcohol dependence after one dose
DIt works only if alcohol is drunk with it, so a small amount of wine is needed daily
24.Mental health nursingHard
A patient is pacing, has clenched fists and is shouting at staff. What is the most appropriate first approach?
ARestrain the patient immediately
BStand close to the patient and raise your voice so that you clearly take control of the situation
CTurn your back and ignore the behaviour
DUse calm verbal de-escalation, keep a safe distance and make sure both of you have an exit
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 11:25 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
11:25
111:25 AM
21:25 AM
310:25 AM
411:25 PM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 3 tsp of cough syrup, 3 cups of tea, 3 tbsp of liquid supplement. Using the equivalents given, find the total oral intake V in mL.
1 tsp = 5 mL1 cup = 8 fl oz = 240 mL1 tbsp = 15 mL
V = mL
27.Dosage calculationsMedium
A patient weighing 28 kg has a body surface area of 1.06 m². The prescription is 135 mg/m². Find the dose D in mg.
28 kgBSA = 1.06 m²135 mg/m²
D = mg
28.Dosage calculationsHard
A patient weighs 147.4 lb. The prescription is 0.5 mg/kg as a single dose, and the stock contains 40 mg in 1 mL. Using 1 kg = 2.2 lb, what volume V do you give? Round to two decimal places.
147.4 lb0.5 mg/kg40 mg/1 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
1000 mL was ordered over 6 hours. After 3 hours you find that 610 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 / 6 hafter 3 h: 610 mL
R = mL/h
30.IV infusion ratesHard
A drip runs at 25 gtt/min through a set of 20 gtt/mL. There are 400 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
25 gtt/min20 gtt/mL400 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 50 units of regular insulin in 50 mL. The order is 0.05 units/kg/h for a patient who weighs 66 kg. Find the pump rate R in mL/h. Round to one decimal place.
50 units/50 mL0.05 units/kg/h66 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 21 mL/h. The patient weighs 62 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
400 mg/250 mL21 mL/h62 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 total intake I in mL.
soup: 150 mLjuice: 120 mLjelly: 100 mLIV infusion: 75 mL/h × 12 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 09:00 and runs by pump at 125 mL/h. How many mL V are left in the bag at 12:00?
1000 mL125 mL/h09:00 → 12:00
V = mL
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: yes; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 119 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?
MAP 65 mmHgSBP 119 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 139 mmol/L, glucose 12.4 mmol/L and urea 8.5 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 139 mmol/Lglucose 12.4 mmol/Lurea 8.5 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 133, Cl⁻ 92 and HCO₃⁻ 15 mmol/L. Calculate the delta ratio (AG − 12)/(24 − HCO₃⁻), using AG = Na⁺ − (Cl⁻ + HCO₃⁻). Give two decimals.
Na⁺ 133 mmol/LCl⁻ 92 mmol/LHCO₃⁻ 15 mmol/L
delta ratio =
39.ECG rhythm strip interpretationMedium
Interpret this lead II rhythm strip. Which rhythm is it? 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
1sinus tachycardia
2junctional rhythm
3first-degree AV block
4normal sinus rhythm
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. Which rhythm is it? 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
1first-degree AV block
2second-degree AV block type II
3third-degree (complete) AV block
4second-degree AV block type I (Wenckebach)
3Solutions
1.Nursing fundamentals
Answer: A · Stomach irritation and bleeding
Why this is the answer
NSAIDs can irritate the stomach lining and cause ulcers and bleeding. They are taken with food, avoided in some patients and may also affect the kidneys.
Answer
A · Stomach irritation and bleeding
2.Nursing fundamentals
Answer: D · Oliguria that should be escalated, as it is below 0.5 mL/kg/h
Why this is the answer
For a 70 kg adult, 0.5 mL/kg/h is 35 mL/h. An output of 20 mL/h for several hours suggests poor kidney perfusion or acute kidney injury. Check the catheter and escalate.
Answer
D · Oliguria that should be escalated, as it is below 0.5 mL/kg/h
3.Infection control & patient safety
Answer: C · Lymphocytes
Why this is the answer
Lymphocytes increase in many viral infections. Neutrophils rise mainly with bacterial infections, and eosinophils with allergies and parasites.
Answer
C · Lymphocytes
4.Infection control & patient safety
Answer: A · Notify the provider and start neurological observations, because a brain bleed may develop
Why this is the answer
Head injury in a patient on anticoagulants can cause bleeding inside the skull that shows signs later. The provider is told at once, imaging may be needed and neurological checks are done closely.
Answer
A · Notify the provider and start neurological observations, because a brain bleed may develop
5.Prioritization & delegation
Answer: A · A patient on a heparin infusion has a new black, tarry stool
Why this is the answer
Black, tarry stool (melena) suggests bleeding from the upper gut, a dangerous complication of anticoagulation. Shoulder pain after laparoscopy from the gas used is common, and a barrel chest in COPD and stable jaundice in cirrhosis are expected.
Answer
A · A patient on a heparin infusion has a new black, tarry stool
6.Prioritization & delegation
Answer: D · Transfusion-associated circulatory overload
Why this is the answer
Breathlessness, crackles and hypertension during a transfusion in a patient with heart failure suggest circulatory overload. The nurse stops the transfusion, sits the patient up, gives oxygen as prescribed and informs the provider, who may prescribe a diuretic.
Answer
D · Transfusion-associated circulatory overload
7.Clinical nursing
Answer: B · Urea (blood urea nitrogen)
Why this is the answer
Blood proteins digested in the upper GI tract are absorbed and converted to urea, so urea rises out of proportion to creatinine. Urea is part of the Glasgow-Blatchford bleeding score.
Answer
B · Urea (blood urea nitrogen)
8.Clinical nursing
Answer: D · Reduce the oxygen to keep the SpO2 within the prescribed target range
Why this is the answer
Oxygen is prescribed to a target range, usually 94–98% for most patients. Once the patient is stable it should be weaned down, as unnecessary hyperoxia has no benefit and can be harmful.
Answer
D · Reduce the oxygen to keep the SpO2 within the prescribed target range
9.Lab values & electrolytes
Answer: D · Adjust the rate as the protocol directs and recheck as scheduled
Why this is the answer
A subtherapeutic aPTT means the patient is not fully anticoagulated and is at risk of clot extension. Weight-based heparin protocols specify a bolus and/or rate increase and when to recheck. The nurse follows the protocol and documents the change.Checked against:Partial Thromboplastin Time (PTT) Test · MedlinePlus (NIH) (2026); Partial thromboplastin time (PTT) - Medical Encyclopedia · MedlinePlus (NIH) (2025)
Answer
D · Adjust the rate as the protocol directs and recheck as scheduled
10.Lab values & electrolytes
Answer: C · High calcium increases the risk of digoxin toxicity
Why this is the answer
Hypercalcemia, like hypokalemia and hypomagnesemia, makes the heart more sensitive to digoxin and raises the risk of toxic arrhythmias. Nausea and bradycardia suggest toxicity, so the nurse holds the dose and reports the findings.
Answer
C · High calcium increases the risk of digoxin toxicity
11.Pharmacology
Answer: A · Factor Xa
Why this is the answer
Apixaban and rivaroxaban are direct factor Xa inhibitors. Dabigatran directly inhibits thrombin, warfarin blocks vitamin K recycling and clopidogrel blocks P2Y12.
Answer
A · Factor Xa
12.Pharmacology
Answer: C · NSAIDs cause salt and water retention and can worsen heart failure
Why this is the answer
NSAIDs inhibit renal prostaglandins, causing sodium and water retention and reducing the effect of diuretics. They can trigger decompensation of heart failure and are usually avoided.
Answer
C · NSAIDs cause salt and water retention and can worsen heart failure
13.Med-surg: cardiovascular & respiratory
Answer: B · To prevent dehydration and keep secretions thinner
Why this is the answer
Fever, sweating and tachypnoea increase insensible fluid loss. Good hydration prevents dehydration and helps keep secretions less sticky. Patients with heart failure or other restrictions need individual plans.
Answer
B · To prevent dehydration and keep secretions thinner
14.Med-surg: cardiovascular & respiratory
Answer: A · Assess the airway, call for urgent help and hold further doses
Why this is the answer
Angioedema is a rare but potentially life-threatening reaction to ACE inhibitors, caused by bradykinin accumulation. Airway compromise is the priority: call for emergency help, monitor airway and breathing closely, and stop the drug permanently. It can occur even after years of use.
Answer
A · Assess the airway, call for urgent help and hold further doses
15.Med-surg: neuro, endocrine & renal
Answer: A · A patient with heart failure
Why this is the answer
Pioglitazone can cause fluid retention and oedema, which can worsen heart failure. It is contraindicated in patients with heart failure. Weight gain and an increased fracture risk are other effects.
Answer
A · A patient with heart failure
16.Med-surg: neuro, endocrine & renal
Answer: B · Contact the prescriber or pharmacist about another route
Why this is the answer
Omitting Parkinson's medication can cause severe rigidity, swallowing failure and, rarely, a life-threatening withdrawal syndrome. Alternatives such as giving it by nasogastric tube or a dopamine agonist patch should be arranged urgently.
Answer
B · Contact the prescriber or pharmacist about another route
17.Med-surg: GI, perioperative & oncology
Answer: B · With the head of the bed raised to reduce swelling
Why this is the answer
Raising the head reduces facial and airway swelling. The airway is monitored closely because swelling can increase over the first 24–48 hours.
Answer
B · With the head of the bed raised to reduce swelling
18.Med-surg: GI, perioperative & oncology
Answer: D · To rescue normal cells from methotrexate toxicity
Why this is the answer
Methotrexate inhibits dihydrofolate reductase. Timed folinic acid bypasses this block in normal cells, reducing toxicity such as mucositis and myelosuppression, while methotrexate levels and kidney function are monitored.
Answer
D · To rescue normal cells from methotrexate toxicity
19.Maternity & obstetric nursing
Answer: A · A large baby of a mother with diabetes
Why this is the answer
High maternal glucose crosses the placenta and the fetus makes extra insulin. After the cord is cut, the glucose supply stops but the insulin stays high. Preterm, small and cold babies are also at risk.
Answer
A · A large baby of a mother with diabetes
20.Maternity & obstetric nursing
Answer: C · "If I feel very angry, it is fine to shake him a little to stop the crying."
Why this is the answer
Shaking a baby can cause brain injury, retinal haemorrhages and death. Parents are taught that crying is normal, to put the baby down safely and step away when frustrated, and to ask for help.
Answer
C · "If I feel very angry, it is fine to shake him a little to stop the crying."
21.Pediatric nursing
Answer: C · Anaphylaxis after a previous dose of that vaccine
Why this is the answer
A severe allergic reaction to a previous dose or to a vaccine component is a contraindication. Local redness and mild fever are common, expected reactions.
Answer
C · Anaphylaxis after a previous dose of that vaccine
22.Pediatric nursing
Answer: A · Blood cultures and prompt IV antibiotics for possible osteomyelitis
Why this is the answer
Acute osteomyelitis in children is most often caused by Staphylococcus aureus. Blood cultures are taken and IV antibiotics started promptly, followed by a long course to prevent bone damage and chronic infection.
Answer
A · Blood cultures and prompt IV antibiotics for possible osteomyelitis
23.Mental health nursing
Answer: A · Avoid all alcohol, including hidden sources such as some mouthwashes and sauces
Why this is the answer
Disulfiram blocks the breakdown of acetaldehyde, so alcohol causes flushing, nausea, vomiting, palpitations and hypotension. Patients must avoid alcohol in any form.
Answer
A · Avoid all alcohol, including hidden sources such as some mouthwashes and sauces
24.Mental health nursing
Answer: D · Use calm verbal de-escalation, keep a safe distance and make sure both of you have an exit
Why this is the answer
De-escalation uses a calm voice, simple language, active listening and offering choices, while keeping a safe distance and an exit route. Restraint is a last resort if there is imminent danger.
Answer
D · Use calm verbal de-escalation, keep a safe distance and make sure both of you have an exit
25.Nursing math & unit conversions
Answer: 11:25 AM
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.
Convert the hour
11 → 11 AM
Answer
11:25 AM
Answer
11:25 AM
26.Nursing math & unit conversions
Answer: V = 780 mL
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Each item in mL
3 tsp = 3·5 = 15 mL
3 cups = 3·240 = 720 mL
3 tbsp = 3·15 = 45 mL
Add
V = 15 + 720 + 45 = 780 mL
Answer
V = 780 mL
27.Dosage calculations
Answer: D = 143.1 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).
Dose
D = 135·1.06 = 143.1 mg
Answer
D = 143.1 mg
28.Dosage calculations
Answer: V = 0.84 mL
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.
Weight in kg
147.4/2.2 = 67 kg
Dose
0.5·67 = 33.5 mg
Volume
V = (33.5/40)·1 = 0.8375 ≈ 0.84 mL
Answer
V = 0.84 mL
29.IV infusion rates
Answer: R = 203.3 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
1000/6 = 166.7 mL/h
New rate
R = 610/3 = 203.3 mL/h
Answer
R = 203.3 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: t = 5.3 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.
Rate in mL/h
25·60/20 = 75 mL/h
Time left
t = 400/75 = 5.333 ≈ 5.3 h
Answer
t = 5.3 h
31.Pediatric & critical-care dosing
Answer: R = 3.3 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
0.05·66 = 3.3 units/h
Concentration
50/50 = 1 units/mL
Pump rate
R = 3.3/1 = 3.3 mL/h
Answer
R = 3.3 mL/h
32.Pediatric & critical-care dosing
Answer: D = 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
400 000/250 = 1600 mcg/mL
Micrograms per minute
21·1600 = 33600 mcg/h
33600/60 = 560 mcg/min
Per kilogram
D = 560/62 = 9.032 ≈ 9 mcg/kg/min
Answer
D = 9 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 1370 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Add the intake
oral: 150 + 120 + 100 = 370 mL
IV infusion: 75·12 = 900 mL
IV antibiotic: 1·100 = 100 mL
I = 1370 mL
Answer
I = 1370 mL
34.IV fluids & fluid balance
Answer: V = 625 mL
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.
Elapsed time
09:00 → 12:00 = 3 h
Volume infused
125·3 = 375 mL
Volume left
V = 1000 − 375 = 625 mL
Answer
V = 625 mL
35.Clinical assessment scores
Answer: MFS = 60
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: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: yes → 20
gait: normal, bed rest or wheelchair → 0
mental status: knows own limits → 0
Add
Morse total = 25 + 15 + 0 + 20 + 0 + 0 = 60
Answer
MFS = 60
36.Clinical assessment scores
Answer: DBP = 38 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·65 − 119)/2 = 76/2 = 38 mmHg
Answer
DBP = 38 mmHg
37.Arterial blood gas interpretation
Answer: Osm = 299 mOsm/kg
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.
Calculated osmolality
Osm = 2·139 + 12.4 + 8.5 = 298.9 ≈ 299 mOsm/kg
Answer
Osm = 299 mOsm/kg
38.Arterial blood gas interpretation
Answer: delta ratio = 1.556
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 = 133 − (92 + 15) = 26
Delta ratio
(26 − 12)/(24 − 15) = 14/9 = 1.556
Answer
delta ratio = 1.556
Between 1 and 2: a pure high anion gap acidosis.
39.ECG rhythm strip interpretation
Answer: normal sinus rhythm
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: R–R = 23 small boxes, 1500 ÷ 23 ≈ 65 per minute.
2. Rhythm: regular, every R–R is 0.92 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
normal sinus rhythm
Answer
normal sinus rhythm
40.ECG rhythm strip interpretation
Answer: third-degree (complete) AV block
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.
Five steps
1. Rate: R–R = 28 small boxes, 1500 ÷ 28 ≈ 54 per minute.
2. Rhythm: R–R regular (1.12 s) and P–P regular (0.68 s), but the two are independent.
3. P waves: upright and regular at 88 per minute, but not linked to the QRS complexes; some hide in a QRS or a T wave.
4. PR interval: varies from beat to beat; there is no fixed relation.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
third-degree (complete) AV block
Answer
third-degree (complete) AV block
Type II and third-degree blocks are the ones that can suddenly progress, so textbooks rank them as more serious than type I.
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