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
A nurse gives a patient analgesia for pain. What is the next important step?
ARecord the dose and assume the pain is gone unless the patient complains
BReassess the pain after the drug has had time to work
CGive a second dose straight away
DWait until the next day to ask about the pain
2.Nursing fundamentalsHard
What is the most common cause of ABO-incompatible blood transfusions?
AGiving blood too slowly
BAllergies to the plastic bag
CErrors in identifying the patient or the sample
DFaulty storage of blood at the wrong temperature
3.Infection control & patient safetyMedium
Why must an insulin pen never be used for more than one patient, even with a new needle?
ABlood can flow back into the cartridge and spread infection
BSharing a pen changes the dose that is delivered
CEach pen holds only one dose of insulin
DThe insulin in the pen would expire faster once it is shared
4.Infection control & patient safetyHard
A woman in late pregnancy is choking and cannot speak or cough. Which technique should the rescuer use?
AChest thrusts
BAbdominal thrusts
CBack blows only
DBlind finger sweeps
5.Prioritization & delegationMedium
Two nursing assistants argue loudly at the station about their assignments. What is the charge nurse’s best first step?
AMeet both of them privately to hear each side
BIgnore it and hope they sort it out
CChange both of their assignments without any discussion
DReport them to human resources at once
6.Prioritization & delegationHard
After the RN taught a patient to inject insulin, an LPN/LVN reports that the patient still cannot draw up the dose correctly. What should happen next?
AThe LPN/LVN writes a new teaching plan and evaluates it at the end of the shift
BThe RN reassesses the patient’s learning needs and adjusts the teaching
CThe patient is discharged with a leaflet to read at home
DThe nursing assistant shows the patient again at lunch
7.Clinical nursingMedium
Why is an urgent brain scan needed before thrombolysis for a suspected stroke?
ATo check for brain tumours only
BTo measure the size of the ventricles
CTo rule out bleeding in the brain
DTo confirm the patient's age
8.Clinical nursingHard
A few hours after cardiac surgery, a patient has low blood pressure, a raised jugular venous pressure and quiet, muffled heart sounds. What should be suspected?
APneumonia
BHypovolaemia from dehydration
CHyperkalaemia
DCardiac tamponade
9.Lab values & electrolytesMedium
A patient’s hemoglobin is 7.8 g/dL (78 g/L). Which findings would the nurse expect?
AFatigue, pallor, a fast heart rate and breathlessness on exertion
BItching, yellow skin and dark urine
CHeadache, nosebleeds and a red face
DA slow heart rate, flushed skin and a high blood pressure
10.Lab values & electrolytesHard
A patient on warfarin with a stable INR of 2.4 starts a course of an antibiotic such as ciprofloxacin. A week later the INR is 4.6. What is the most likely explanation?
AA drug interaction that increases the effect of warfarin
BThe patient has eaten more vitamin K–rich food
CThe antibiotic has cured the patient’s need for anticoagulation
DA laboratory error is the only possible explanation
11.PharmacologyMedium
Which blood test is used to monitor warfarin therapy?
APlatelet count
BSerum albumin
CActivated partial thromboplastin time (aPTT)
DINR (prothrombin time)
12.PharmacologyHard
Two days after starting chemotherapy for a leukaemia with a high white cell count, a patient has reduced urine output. Which lab pattern suggests tumour lysis syndrome?
ANormal electrolytes with a high haemoglobin
BHigh sodium, high glucose and low potassium
CHigh potassium, high phosphate, high uric acid and low calcium
DLow potassium, low phosphate, low uric acid and high calcium
13.Med-surg: cardiovascular & respiratoryMedium
A patient taking simvastatin drinks a large glass of grapefruit juice every morning. Why is this a concern?
AIt turns the statin into a blood thinner
BIt raises statin levels and the risk of muscle damage
CIt causes the cholesterol level to rise sharply
DIt stops the statin from being absorbed from the gut at all
14.Med-surg: cardiovascular & respiratoryHard
A patient with a large pericardial effusion has a systolic pressure that falls by more than 10 mmHg during inspiration. What is this finding called?
APulsus paradoxus
BPulsus alternans
CA collapsing pulse
DA pulse deficit
15.Med-surg: neuro, endocrine & renalMedium
Which group of problems is typical of primary hyperparathyroidism?
AMuscle cramps, tingling lips and seizures
BHair loss, weight gain and feeling cold
CKidney stones, bone pain, abdominal pain and low mood
DHeat intolerance, tremor, weight loss and diarrhoea
16.Med-surg: neuro, endocrine & renalHard
A patient with AKI has a low urine sodium and concentrated urine. What does this suggest?
AA post-renal blockage, with urine backed up
BDiabetes insipidus, with too little ADH
CAcute tubular necrosis, with damaged and leaking tubules
DA pre-renal cause, with kidneys holding salt and water
17.Med-surg: GI, perioperative & oncologyMedium
Which statement about moist wound healing is correct?
AWounds should be soaked in water for hours every day
BA wet wound bed always prevents infection
CA moist, not wet, wound bed helps cells move and heal faster
DWounds heal fastest when left to dry out and form a scab
18.Med-surg: GI, perioperative & oncologyHard
A patient's ileostomy output is 2.5 L a day. They feel tired and dizzy and are drinking large amounts of water. Which advice is usually appropriate?
AStop all drinking for 24 hours
BEat only fruit and fruit juice
CLimit plain drinks and use an oral rehydration solution
DDrink even more plain water and tea to replace the losses
19.Maternity & obstetric nursingMedium
A woman at 39 weeks with a healthy pregnancy asks about walking in early labour. What is the best advice?
AWalking and upright positions can help progress
BWalking will cause the cord to prolapse
CUpright positions always make labour slower
DShe must stay in bed on her back for the whole labour
20.Maternity & obstetric nursingHard
After birth of the head, the nurse feels the umbilical cord loosely around the baby's neck. What is the appropriate action?
ASlip the loop over the head or let the body deliver through it
BAsk the woman to stop pushing for 30 minutes
CClamp and cut the cord before the shoulders deliver in every case
DPush the baby's head back into the vagina
21.Pediatric nursingMedium
Which measure is most important in preventing infection in a child with neutropenia?
AWearing a mask only when the child has a fever
BKeeping all visitors, including the parents, out of the child's room
CCareful hand hygiene by everyone in contact with the child
DGiving routine antibiotics to all family members
22.Pediatric nursingHard
Which statement by the parent of a child with peanut allergy shows a need for further teaching?
A"I'll call an ambulance every time I use the auto-injector, even if she seems to recover quickly."
B"If she has a bad reaction, I'll give an antihistamine and wait an hour before using the auto-injector."
C"I'll read food labels for peanuts every time I shop."
D"I'll check the use-by date on her auto-injectors regularly and replace them before they expire."
23.Mental health nursingMedium
Which treatment is recommended first-line for chronic insomnia in adults?
ADrinking alcohol in the evening to fall asleep
BLong-term daily benzodiazepines
CCognitive behavioural therapy for insomnia (CBT-I)
DStaying in bed for longer each morning
24.Mental health nursingHard
A nurse teaches a family member how to use a naloxone kit. Which statement shows a need for further teaching?
A"If he doesn't respond, I may need to give a second dose."
B"Once I've given the naloxone, I don't need to call an ambulance."
C"I'll check his breathing and put him in the recovery position if he is breathing but still not awake."
D"I'll stay with him, because the overdose can come back."
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 3:20 PM. Which entry is the same time on the 24-hour clock? Click it.
3:20 PM
114:20
215:20
303:20
416:20
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 25 mcg/min. Express this dose rate D in mg/h.
25 mcg/min1 h = 60 min1 mg = 1000 mcg
D = mg/h
27.Dosage calculationsMedium
A vial contains 500 mg of powder. The label says: add 9.6 mL of water for injection to give a total volume of 10 mL. The prescription is 30 mg. What volume V of the reconstituted solution do you give?
500 mg+ 9.6 mL → 10 mL30 mg
V = mL
28.Dosage calculationsHard
The prescription is 8700 units of a drug that comes as 10000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
8700 units10000 units/mL
V = mL
29.IV infusion ratesMedium
1000 mL was ordered over 6 hours. After 4 hours you find that 380 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 4 h: 380 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 200 mg of a drug in 250 mL and runs at 5 mL/h. How many milligrams per hour D does the patient receive?
200 mg/250 mL5 mL/h
D = mg/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 8 units/h. Find the pump rate R in mL/h. Round to one decimal place.
50 units/50 mL8 units/h
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 11 mL/h. The patient weighs 63 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
800 mg/500 mL11 mL/h63 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 12:45 and runs by pump at 50 mL/h. How many mL V are left in the bag at 16:45?
500 mL50 mL/h12:45 → 16:45
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 126/min and a blood pressure of 168/109 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 126/minBP 168/109 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 14/min, SpO₂ 98% on room air, blood pressure 88/52 mmHg, pulse 70/min, alert, temperature 36.4 °C. Which clinical risk group does the patient fall into? Click it.
RR 14SpO₂ 98%airSBP 88HR 70AT 36.4 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.55, PaCO₂ 39 mmHg (5.2 kPa) and HCO₃⁻ 33 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.55PaCO₂ 39 mmHg (5.2 kPa)HCO₃⁻ 33 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.32, PaCO₂ 30 mmHg (4.0 kPa), HCO₃⁻ 15 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.32PaCO₂ 30 mmHg (4.0 kPa)HCO₃⁻ 15 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
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
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
1second-degree AV block type II
2first-degree AV block
32:1 AV block (type undetermined)
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: B · Reassess the pain after the drug has had time to work
Why this is the answer
Pain should be reassessed after an interval that matches the drug and route. This shows whether the treatment works and whether side effects such as sedation have appeared.
Answer
B · Reassess the pain after the drug has had time to work
2.Nursing fundamentals
Answer: C · Errors in identifying the patient or the sample
Why this is the answer
Most wrong-blood events come from identification errors, for example a mislabelled sample or skipping the bedside identity check. Positive patient identification at every step prevents them.
Answer
C · Errors in identifying the patient or the sample
3.Infection control & patient safety
Answer: A · Blood can flow back into the cartridge and spread infection
Why this is the answer
Blood and skin cells can be drawn back into the cartridge, so sharing a pen can transmit bloodborne infections. Each pen is labeled for a single patient.
Answer
A · Blood can flow back into the cartridge and spread infection
4.Infection control & patient safety
Answer: A · Chest thrusts
Why this is the answer
For people in late pregnancy or who are very obese, chest thrusts replace abdominal thrusts because the rescuer cannot get around the abdomen effectively. Blind finger sweeps can push the object deeper.
Answer
A · Chest thrusts
5.Prioritization & delegation
Answer: A · Meet both of them privately to hear each side
Why this is the answer
Talking with both staff members privately allows the charge nurse to understand the problem and look for a fair solution. Ignoring the conflict or acting without facts usually makes it worse.
Answer
A · Meet both of them privately to hear each side
6.Prioritization & delegation
Answer: B · The RN reassesses the patient’s learning needs and adjusts the teaching
Why this is the answer
Evaluating learning and changing the teaching plan belong to the RN. The LPN/LVN can reinforce teaching, but a teaching plan that is not working needs RN reassessment.
Answer
B · The RN reassesses the patient’s learning needs and adjusts the teaching
7.Clinical nursing
Answer: C · To rule out bleeding in the brain
Why this is the answer
A CT scan distinguishes haemorrhagic from ischaemic stroke. Clot-busting drugs are only given when bleeding has been excluded and other criteria are met.
Answer
C · To rule out bleeding in the brain
8.Clinical nursing
Answer: D · Cardiac tamponade
Why this is the answer
Hypotension, raised JVP and muffled heart sounds (Beck's triad) suggest cardiac tamponade. Blood in the pericardial space compresses the heart and needs urgent drainage.
Answer
D · Cardiac tamponade
9.Lab values & electrolytes
Answer: A · Fatigue, pallor, a fast heart rate and breathlessness on exertion
Why this is the answer
Anemia reduces oxygen delivery. The heart beats faster to compensate, and the patient feels tired and breathless with activity and looks pale. Severe anemia can cause chest pain in people with heart disease.Checked against:Anemia · MedlinePlus (NIH) (2026)
Answer
A · Fatigue, pallor, a fast heart rate and breathlessness on exertion
10.Lab values & electrolytes
Answer: A · A drug interaction that increases the effect of warfarin
Why this is the answer
Several antibiotics increase warfarin’s effect by reducing its breakdown or by changing gut bacteria that make vitamin K. The INR is monitored more often when such drugs are started. More vitamin K in the diet would lower the INR.Checked against:Taking warfarin · MedlinePlus (NIH) (2025)
Answer
A · A drug interaction that increases the effect of warfarin
11.Pharmacology
Answer: D · INR (prothrombin time)
Why this is the answer
Warfarin is monitored with the INR, a standardised prothrombin time. For most indications, such as atrial fibrillation or venous thrombosis, the target is usually 2–3.
Answer
D · INR (prothrombin time)
12.Pharmacology
Answer: C · High potassium, high phosphate, high uric acid and low calcium
Why this is the answer
Rapid tumour cell death releases potassium, phosphate and nucleic acids (which become uric acid). Phosphate binds calcium, lowering it; prevention includes IV fluids and drugs that lower uric acid.
Answer
C · High potassium, high phosphate, high uric acid and low calcium
13.Med-surg: cardiovascular & respiratory
Answer: B · It raises statin levels and the risk of muscle damage
Why this is the answer
Grapefruit juice inhibits the CYP3A4 enzyme, increasing levels of drugs such as simvastatin and some calcium channel blockers. Higher statin levels raise the risk of myopathy. Patients are advised to avoid large amounts or choose a statin not affected.
Answer
B · It raises statin levels and the risk of muscle damage
14.Med-surg: cardiovascular & respiratory
Answer: A · Pulsus paradoxus
Why this is the answer
Pulsus paradoxus is an exaggerated inspiratory fall in systolic pressure (more than 10 mmHg). In tamponade, the right ventricle fills on inspiration and pushes the septum left, reducing left ventricular output. It also occurs in severe asthma. A collapsing pulse suggests aortic regurgitation.
Answer
A · Pulsus paradoxus
15.Med-surg: neuro, endocrine & renal
Answer: C · Kidney stones, bone pain, abdominal pain and low mood
Why this is the answer
High PTH raises calcium, which can cause kidney stones, bone loss and pain, constipation and abdominal pain, and low mood or confusion ("stones, bones, groans and moans"). Many cases are found on routine blood tests.
Answer
C · Kidney stones, bone pain, abdominal pain and low mood
16.Med-surg: neuro, endocrine & renal
Answer: D · A pre-renal cause, with kidneys holding salt and water
Why this is the answer
In pre-renal AKI, the tubules work normally and conserve sodium and water, so urine sodium is low and urine is concentrated. In acute tubular necrosis, damaged tubules cannot conserve sodium, so urine sodium is higher.
Answer
D · A pre-renal cause, with kidneys holding salt and water
17.Med-surg: GI, perioperative & oncology
Answer: C · A moist, not wet, wound bed helps cells move and heal faster
Why this is the answer
A moist environment supports cell migration, autolytic debridement and less pain. Too much moisture causes maceration, so dressings are chosen to balance exudate.
Answer
C · A moist, not wet, wound bed helps cells move and heal faster
18.Med-surg: GI, perioperative & oncology
Answer: C · Limit plain drinks and use an oral rehydration solution
Why this is the answer
In high-output stomas, hypotonic drinks increase sodium loss through the stoma. Restricting them and using a glucose–salt oral rehydration solution, with antimotility drugs as prescribed and medical review, helps correct dehydration.
Answer
C · Limit plain drinks and use an oral rehydration solution
19.Maternity & obstetric nursing
Answer: A · Walking and upright positions can help progress
Why this is the answer
Upright positions and mobility in the first stage can shorten labour and reduce the need for epidurals. She can choose positions that feel comfortable.
Answer
A · Walking and upright positions can help progress
20.Maternity & obstetric nursing
Answer: A · Slip the loop over the head or let the body deliver through it
Why this is the answer
A loose nuchal cord can usually be slipped over the head or the baby can be born through it (somersault manoeuvre). Clamping and cutting before birth is reserved for a tight cord that prevents delivery.
Answer
A · Slip the loop over the head or let the body deliver through it
21.Pediatric nursing
Answer: C · Careful hand hygiene by everyone in contact with the child
Why this is the answer
Thorough hand hygiene by staff, family and the child is the single most important measure. Avoiding contact with people who are unwell, good mouth and skin care and safe food handling also help.
Answer
C · Careful hand hygiene by everyone in contact with the child
22.Pediatric nursing
Answer: B · "If she has a bad reaction, I'll give an antihistamine and wait an hour before using the auto-injector."
Why this is the answer
Adrenaline is the first treatment for anaphylaxis and must be given without delay; antihistamines do not treat airway swelling or shock. Checking expiry dates, reading labels and calling emergency services after use are correct.
Answer
B · "If she has a bad reaction, I'll give an antihistamine and wait an hour before using the auto-injector."
23.Mental health nursing
Answer: C · Cognitive behavioural therapy for insomnia (CBT-I)
Why this is the answer
CBT-I combines sleep education, stimulus control, sleep restriction and work on unhelpful beliefs about sleep. It has lasting effects and fewer risks than long-term sleeping tablets.
Answer
C · Cognitive behavioural therapy for insomnia (CBT-I)
24.Mental health nursing
Answer: B · "Once I've given the naloxone, I don't need to call an ambulance."
Why this is the answer
Naloxone is short-acting, so the opioid effect can return. Emergency services must always be called, and the person must be watched until help arrives.
Answer
B · "Once I've given the naloxone, I don't need to call an ambulance."
25.Nursing math & unit conversions
Answer: 15:20
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
3 PM → 3 + 12 = 15
Answer
15:20
Answer
15:20
26.Nursing math & unit conversions
Answer: D = 1.5 mg/h
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 25 mcg/min × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 25·60/1000 = 1.5 mg/h
Answer
D = 1.5 mg/h
27.Dosage calculations
Answer: V = 0.6 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.
Concentration after mixing
500 mg/10 mL = 50 mg/mL
Volume
V = 30/50 = 0.6 mL
Answer
V = 0.6 mL
28.Dosage calculations
Answer: V = 0.87 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.
Volume
V = 8700/10000 = 0.87 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.87 mL
29.IV infusion rates
Answer: R = 190 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 = 380/2 = 190 mL/h
Answer
R = 190 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: D = 4 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
200/250 = 0.8 mg/mL
Dose rate
D = 0.8·5 = 4 mg/h
Answer
D = 4 mg/h
31.Pediatric & critical-care dosing
Answer: R = 8 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
50/50 = 1 units/mL
Pump rate
R = 8/1 = 8 mL/h
Answer
R = 8 mL/h
32.Pediatric & critical-care dosing
Answer: D = 4.7 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
800 000/500 = 1600 mcg/mL
Micrograms per minute
11·1600 = 17600 mcg/h
17600/60 = 293.3 mcg/min
Per kilogram
D = 293.3/63 = 4.656 ≈ 4.7 mcg/kg/min
Answer
D = 4.7 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = −100 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: 150 + 180 = 330 mL
ice chips: 200/2 = 100 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 2·50 = 100 mL
total intake = 1250 mL
Total output
450 + 500 + 400 = 1350 mL
Balance
B = 1250 − 1350 = −100 mL
Answer
B = −100 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: V = 300 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
12:45 → 16:45 = 4 h
Volume infused
50·4 = 200 mL
Volume left
V = 500 − 200 = 300 mL
Answer
V = 300 mL
35.Clinical assessment scores
Answer: SI = 0.75
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.
Shock index
SI = 126/168 = 0.75
Answer
SI = 0.75
Above the usual 0.5–0.7.
36.Clinical assessment scores
Answer: low–medium
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 14/min → 0
SpO₂ 98% → 0
on air → 0
SBP 88 mmHg → 3
HR 70/min → 0
alert (A) → 0
T 36.4 °C → 0
Total and red scores
NEWS2 = 0 + 0 + 0 + 3 + 0 + 0 + 0 = 3
At least one parameter scores 3.
Risk group
low–medium
Answer
low–medium
A single score of 3 needs an urgent review even when the total is low.
37.Arterial blood gas interpretation
Answer: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.55: alkalaemia (above 7.45)
PaCO₂ 39 mmHg: normal (35–45)
HCO₃⁻ 33 mmol/L: high (22–26)
Compensation
Clinically, also check the expected compensation: for a metabolic alkalosis PaCO₂ ≈ 0.7·HCO₃⁻ + 21 = 42.1–46.1 mmHg, so the measured 39 mmHg points to an additional respiratory alkalosis (a mixed disorder). The answer above is the ROME exam classification.
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: appropriate compensation
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 PaCO₂
1.5·15 + 8 = 30.5 → 28.5–32.5 mmHg
Compare
measured: 30 mmHg → appropriate compensation
Answer
appropriate compensation
39.ECG rhythm strip interpretation
Answer: QT = 0.44 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
11 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 11 × 0.04 s = 0.44 s
Answer
QT = 0.44 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 1.08 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 = 40 small boxes, 1500 ÷ 40 ≈ 38 per minute.
2. Rhythm: regular, every R–R is 1.60 s.
3. P waves: upright and regular (P–P 0.80 s, 75 per minute), two for every QRS.
4. PR interval: constant at 0.20 s in the conducted beats.
5. QRS: 0.08 s, narrow (below 0.12 s).
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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