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
How can nurses help patients sleep better on a hospital ward at night?
AGive every patient a sleeping tablet
BGroup care and observations so patients are disturbed less often
CDo routine tasks such as bed changes at midnight while it is quiet
DKeep the main lights on so staff can see clearly
2.Nursing fundamentalsHard
Which newly started medication most increases an older patient's risk of falling?
AA vitamin D supplement
BRegular paracetamol (acetaminophen) for back pain
CAn emollient cream for dry skin
DA night-time sedative such as a benzodiazepine
3.Infection control & patient safetyMedium
A parent calls because a toddler has swallowed some household cleaner. The child is awake and breathing normally. What should the nurse advise first?
AContact the local poison advice service now for specific advice
BWait to see whether any symptoms develop over the next day
CGive syrup of ipecac from the medicine cabinet
DMake the child vomit, using a finger at the back of the throat
4.Infection control & patient safetyHard
A nurse has a needlestick from a patient with hepatitis B. The nurse finished the vaccine series and has a documented protective antibody level. Which statement is correct?
ANo reporting is needed because the nurse is immune
BThe nurse must stop all patient care for six months
CNo hepatitis B treatment is needed, but the injury is still reported and followed up
DHepatitis B immune globulin and a complete new vaccine series are both needed at once
5.Prioritization & delegationMedium
A patient taking clozapine reports a sore throat and fever. What is the priority action?
AHold the dose and report so the white cell count can be checked
BOffer throat lozenges and continue the usual dose
CAdvise the patient to gargle with warm salt water and rest in bed
DIncrease the dose because the symptoms suggest a relapse
6.Prioritization & delegationHard
A patient has a heart rate of 38/min, feels dizzy and has a blood pressure of 80/50 mmHg. Which drug is usually given first, as prescribed?
AAtropine
BMetoprolol
CDiltiazem
DDigoxin
7.Clinical nursingMedium
Which is the correct technique for using a metered-dose inhaler without a spacer?
APress the canister twice quickly, then breathe in fast and breathe straight out again
BBreathe in quickly through the nose while pressing the canister
CPress the canister and wait one minute before breathing in
DBreathe out, then breathe in slowly and deeply while pressing the canister, then hold
8.Clinical nursingHard
A patient taking dapagliflozin is vomiting and unwell, with high blood ketones and a blood glucose of only 11 mmol/L (198 mg/dL). What should be suspected?
AHyperosmolar hyperglycaemic state
BHypoglycaemia
CSimple gastroenteritis with no further concern
DEuglycaemic diabetic ketoacidosis
9.Lab values & electrolytesMedium
A patient on warfarin started eating large daily portions of kale and spinach. The INR has fallen. What advice is most appropriate?
AKeep the intake of vitamin K–rich foods steady from day to day
BNever eat green vegetables again
CStop warfarin until the diet is normal
DDouble the warfarin dose without telling the prescriber
10.Lab values & electrolytesHard
A patient with suspected Cushing syndrome takes dexamethasone at night. The next morning, the cortisol is still high. What does this suggest?
AThe patient has primary hypothyroidism instead
BThe result is normal, as dexamethasone raises cortisol
CThe adrenal glands are not able to produce enough cortisol
DCortisol is being produced without normal feedback control
11.PharmacologyMedium
A malnourished patient with alcohol dependence needs IV glucose. Which vitamin should be given before or with it?
AVitamin D
BThiamine (vitamin B1)
CVitamin K (phytomenadione)
DVitamin C
12.PharmacologyHard
Before starting long-term bisphosphonate treatment, a patient is advised to have a dental check-up. Why?
ABisphosphonates dissolve tooth enamel within weeks
BBisphosphonates cause severe gum overgrowth
CThey are linked to osteonecrosis of the jaw after dental surgery
DBisphosphonates stain the teeth black if taken for many years
13.Med-surg: cardiovascular & respiratoryMedium
A patient with a long QT interval develops a polymorphic ventricular tachycardia that twists around the baseline but still has a pulse. Which drug is used first?
AIntravenous adenosine
BOral digoxin
CIntravenous magnesium sulfate
DIntravenous potassium chloride as a bolus
14.Med-surg: cardiovascular & respiratoryHard
An older ex-smoker has a dry cough and worsening breathlessness over a year, finger clubbing and fine "Velcro-like" crackles at both bases at the end of inspiration. Which condition is most likely?
AAn acute asthma attack
BSpontaneous pneumothorax
CIdiopathic pulmonary fibrosis
DCommunity-acquired pneumonia
15.Med-surg: neuro, endocrine & renalMedium
Before a haemodialysis catheter is used, why is the lock solution withdrawn from each lumen?
AIt contains the patient's urine
BIt contains a strong antibiotic that must be kept
CIt contains air that keeps the line open
DIt contains concentrated anticoagulant
16.Med-surg: neuro, endocrine & renalHard
A patient with CKD has a haemoglobin of 92 g/L and starts an erythropoiesis-stimulating agent (ESA). What should the nurse monitor?
ABlood pressure and haemoglobin, as overshoot raises clot risk
BBlood glucose, because ESAs often cause hypoglycaemia
CLiver enzymes, because ESAs are toxic to the liver
DHearing, because ESAs can damage the inner ear
17.Med-surg: GI, perioperative & oncologyMedium
Which lung problem is a known toxicity of bleomycin?
ALung cancer within weeks
BPulmonary fibrosis
CAsthma from pollen
DPneumothorax from coughing
18.Med-surg: GI, perioperative & oncologyHard
Which preoperative task can a registered nurse usually delegate to a healthcare assistant (nursing assistant)?
ATeaching the patient how to use a PCA pump
BAssessing the patient's understanding of the surgery
CDeciding whether abnormal results need reporting
DRecording baseline vital signs
19.Maternity & obstetric nursingMedium
A woman is about to get out of bed for the first time after birth. What should the nurse do?
AHelp her sit, then stand slowly with support
BAsk her to stand quickly to reduce dizziness
CWait until day 3 before letting her stand
DLet her walk alone so she feels independent
20.Maternity & obstetric nursingHard
A woman at 31 weeks with contractions has a negative fetal fibronectin test. What does this result mean?
AThe fetus has an infection
BBirth within the next 1 to 2 weeks is unlikely
CBirth will certainly occur within 48 hours
DThe membranes have ruptured
21.Pediatric nursingMedium
How should an infant with heart failure be fed?
ALarge feeds every 6 hours so the baby can rest in between
BStop the feed when the baby tires and wait until the next scheduled feed
CSmall, frequent feeds with rest breaks, using higher-energy milk if prescribed
DLying flat on the back so the baby does not need to hold the head up
22.Pediatric nursingHard
A 15-year-old asks the nurse to keep her sexual activity confidential from her parents. There are no signs of abuse or risk of serious harm. What is the most appropriate response?
APromise that nothing she says will ever be shared with anyone, whatever she discloses in the future
BRespect her confidentiality, give information and explain when information would have to be shared
CTell her parents straight away
DRefuse to discuss it until her parents are present
23.Mental health nursingMedium
A young person who took LSD at a festival is frightened by what he is seeing. What is the most helpful nursing approach?
AStay with him in a calm, quiet place and reassure him that the effects are from the drug and will pass
BArgue with him that what he sees is not real until he accepts it
CShine a bright light in his eyes every few minutes to check his pupils and keep him alert until it wears off
DLeave him alone in a dark room so that he can sleep it off
24.Mental health nursingHard
A patient says, "My boss didn't say hello this morning, so she must think I'm useless." Which cognitive distortion is shown, and what is a helpful nursing response?
ACatastrophising; tell the patient that she will definitely not be fired
BPersonalisation; advise the patient to ask for a new manager
CMind reading; ask what other reasons there might be for the boss's behaviour
DAll-or-nothing thinking; agree that the boss is being unfair
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 6:05 PM. Which entry is the same time on the 24-hour clock? Click it.
6:05 PM
106:05
217:05
318:05
419:05
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 patient weighing 14 kg has a body surface area of 0.6 m². The prescription is 135 mg/m². Find the dose D in mg.
14 kgBSA = 0.6 m²135 mg/m²
D = mg
28.Dosage calculationsHard
You must prepare 100 mL of a 2% (w/v) solution from a 10% (w/v) stock solution. How much water W must be added to the stock?
C₁ = 10%C₂ = 2%V₂ = 100 mL
W = mL
29.IV infusion ratesMedium
Infuse 250 mL over 8 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
250 mL8 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 500 mg of a drug in 50 mL and runs at 30 mL/h. How many milligrams per hour D does the patient receive?
500 mg/50 mL30 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 250 units of regular insulin in 250 mL. The order is 0.05 units/kg/h for a patient who weighs 94 kg. Find the pump rate R in mL/h. Round to one decimal place.
250 units/250 mL0.05 units/kg/h94 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 500 mg in 250 mL runs at 37 mL/h. The patient weighs 69 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
500 mg/250 mL37 mL/h69 kg
D = mcg/kg/min
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The patient weighs 82 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 13:30 and runs by pump at 150 mL/h. How many mL V are left in the bag at 16:30?
500 mL150 mL/h13:30 → 16:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 105/min and a blood pressure of 158/103 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 105/minBP 158/103 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: completely limited; moisture: constantly moist; activity: bedfast; mobility: completely immobile; nutrition: excellent; friction and shear: problem. Use the bands 19–23 not at risk, 15–18 mild, 13–14 moderate, 10–12 high and 9 or below very high. Click the risk level.
1not at risk
2mild risk
3moderate risk
4high risk
5very high risk
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.37, PaCO₂ 25 mmHg (3.3 kPa) and HCO₃⁻ 14 mmol/L. The primary disorder is metabolic acidosis. How far is it compensated? Click your answer.
pH 7.37PaCO₂ 25 mmHg (3.3 kPa)HCO₃⁻ 14 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.17, PaCO₂ 48 mmHg (6.4 kPa), HCO₃⁻ 17 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.17PaCO₂ 48 mmHg (6.4 kPa)HCO₃⁻ 17 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
39.ECG rhythm strip interpretationMedium
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Fridericia’s formula QTc = QT/∛RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
Identify the rhythm on this lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1idioventricular rhythm
2atrial flutter, 2:1 conduction
3supraventricular tachycardia (SVT)
4torsades de pointes
3Solutions
1.Nursing fundamentals
Answer: B · Group care and observations so patients are disturbed less often
Why this is the answer
Clustering care, dimming lights, reducing noise and offering eye masks or earplugs improve sleep. Sedatives carry risks and are not routine.
Answer
B · Group care and observations so patients are disturbed less often
2.Nursing fundamentals
Answer: D · A night-time sedative such as a benzodiazepine
Why this is the answer
Sedatives cause drowsiness, slowed reactions and unsteadiness, especially at night and in older adults. Diuretics and drugs that lower blood pressure also raise falls risk.
Answer
D · A night-time sedative such as a benzodiazepine
3.Infection control & patient safety
Answer: A · Contact the local poison advice service now for specific advice
Why this is the answer
A poison advice service (poison control in the US, or NHS 111 in the UK) can give advice for the exact product. Inducing vomiting is not recommended, because corrosive products can burn the esophagus again and vomit can be aspirated. Emergency services are called if the child has trouble breathing or is drowsy.
Answer
A · Contact the local poison advice service now for specific advice
4.Infection control & patient safety
Answer: C · No hepatitis B treatment is needed, but the injury is still reported and followed up
Why this is the answer
A documented vaccine responder is protected against hepatitis B and needs no hepatitis B prophylaxis. The exposure is still reported, because the nurse and source patient need assessment for HIV and hepatitis C as well.
Answer
C · No hepatitis B treatment is needed, but the injury is still reported and followed up
5.Prioritization & delegation
Answer: A · Hold the dose and report so the white cell count can be checked
Why this is the answer
Clozapine can cause agranulocytosis. A sore throat or fever may be the first sign of infection, so the nurse reports it and the neutrophil count is checked before more doses are given.
Answer
A · Hold the dose and report so the white cell count can be checked
6.Prioritization & delegation
Answer: A · Atropine
Why this is the answer
Atropine is the first-line drug for symptomatic bradycardia. Metoprolol, digoxin and diltiazem slow the heart and would make things worse; pacing may be needed if atropine does not work.
Answer
A · Atropine
7.Clinical nursing
Answer: D · Breathe out, then breathe in slowly and deeply while pressing the canister, then hold
Why this is the answer
The patient breathes out, seals the lips around the mouthpiece, starts breathing in slowly, presses the canister and continues a deep breath, then holds it for about 10 seconds. Spacers make coordination easier.
Answer
D · Breathe out, then breathe in slowly and deeply while pressing the canister, then hold
8.Clinical nursing
Answer: D · Euglycaemic diabetic ketoacidosis
Why this is the answer
SGLT2 inhibitors can cause DKA with near-normal or modestly raised glucose because glucose is lost in the urine. Ketones should be checked in unwell patients on these drugs.
Answer
D · Euglycaemic diabetic ketoacidosis
9.Lab values & electrolytes
Answer: A · Keep the intake of vitamin K–rich foods steady from day to day
Why this is the answer
Vitamin K counteracts warfarin, so a large increase in leafy greens lowers the INR. Patients do not have to avoid these foods, but they should keep the amount consistent so the dose can be set correctly.Checked against:Warfarin · MedlinePlus (NIH) (2026); Taking warfarin · MedlinePlus (NIH) (2025)
Answer
A · Keep the intake of vitamin K–rich foods steady from day to day
10.Lab values & electrolytes
Answer: D · Cortisol is being produced without normal feedback control
Why this is the answer
Dexamethasone normally suppresses ACTH and lowers morning cortisol. Failure to suppress suggests autonomous cortisol excess (Cushing syndrome). Further tests then find the source, such as a pituitary or adrenal tumor.
Answer
D · Cortisol is being produced without normal feedback control
11.Pharmacology
Answer: B · Thiamine (vitamin B1)
Why this is the answer
Giving glucose without thiamine to a thiamine-deficient patient can trigger or worsen Wernicke's encephalopathy. Thiamine is therefore given before or alongside glucose.
Answer
B · Thiamine (vitamin B1)
12.Pharmacology
Answer: C · They are linked to osteonecrosis of the jaw after dental surgery
Why this is the answer
Osteonecrosis of the jaw is a rare but serious adverse effect, mostly after invasive dental work. Dental problems are treated before starting, and good oral hygiene is maintained.
Answer
C · They are linked to osteonecrosis of the jaw after dental surgery
13.Med-surg: cardiovascular & respiratory
Answer: C · Intravenous magnesium sulfate
Why this is the answer
Torsades de pointes is treated with IV magnesium, plus correction of low potassium and stopping drugs that prolong the QT interval. If the patient loses their pulse, defibrillation is needed. Potassium must never be given as an IV bolus.
Answer
C · Intravenous magnesium sulfate
14.Med-surg: cardiovascular & respiratory
Answer: C · Idiopathic pulmonary fibrosis
Why this is the answer
Idiopathic pulmonary fibrosis causes progressive breathlessness, a dry cough, clubbing and fine end-inspiratory crackles. Spirometry shows a restrictive pattern and CT shows fibrosis. Treatment includes antifibrotic drugs, pulmonary rehabilitation, oxygen and palliative care.
Answer
C · Idiopathic pulmonary fibrosis
15.Med-surg: neuro, endocrine & renal
Answer: D · It contains concentrated anticoagulant
Why this is the answer
Dialysis catheter lumens are filled with a concentrated heparin or citrate lock. If it is flushed into the patient, it can cause bleeding or other effects. Catheters are usually accessed only by trained staff.
Answer
D · It contains concentrated anticoagulant
16.Med-surg: neuro, endocrine & renal
Answer: A · Blood pressure and haemoglobin, as overshoot raises clot risk
Why this is the answer
ESAs can cause hypertension and, when haemoglobin is pushed too high, increase the risk of thrombosis and stroke. Haemoglobin is targeted to a moderate range (commonly about 100–120 g/L). Iron stores are checked because iron deficiency limits the response.
Answer
A · Blood pressure and haemoglobin, as overshoot raises clot risk
17.Med-surg: GI, perioperative & oncology
Answer: B · Pulmonary fibrosis
Why this is the answer
Bleomycin can cause pneumonitis and pulmonary fibrosis, especially at higher cumulative doses, in older patients and with high oxygen concentrations. Breathlessness or a new cough must be reported.
Answer
B · Pulmonary fibrosis
18.Med-surg: GI, perioperative & oncology
Answer: D · Recording baseline vital signs
Why this is the answer
Trained assistants can record routine observations and report them. Assessment, teaching and interpreting results need registered nurse knowledge and judgement.
Answer
D · Recording baseline vital signs
19.Maternity & obstetric nursing
Answer: A · Help her sit, then stand slowly with support
Why this is the answer
Orthostatic hypotension is common after birth. The nurse helps her sit at the edge of the bed, dangle her legs, then stand slowly with assistance and stays close in case she feels faint.
Answer
A · Help her sit, then stand slowly with support
20.Maternity & obstetric nursing
Answer: B · Birth within the next 1 to 2 weeks is unlikely
Why this is the answer
Fetal fibronectin is a protein that binds the membranes to the uterine lining. A negative result has a high negative predictive value, meaning birth within 7 to 14 days is unlikely; a positive result is less predictive.
Answer
B · Birth within the next 1 to 2 weeks is unlikely
21.Pediatric nursing
Answer: C · Small, frequent feeds with rest breaks, using higher-energy milk if prescribed
Why this is the answer
Infants with heart failure use a lot of energy and tire easily. Small, frequent feeds, rest breaks, a semi-upright position and energy-dense milk help them grow; tube feeding may be needed if they cannot take enough.
Answer
C · Small, frequent feeds with rest breaks, using higher-energy milk if prescribed
22.Pediatric nursing
Answer: B · Respect her confidentiality, give information and explain when information would have to be shared
Why this is the answer
Adolescents have a right to confidential care within the law. The nurse explains that information may be shared if there is a risk of serious harm, for example abuse or exploitation, but should not promise absolute secrecy.
Answer
B · Respect her confidentiality, give information and explain when information would have to be shared
23.Mental health nursing
Answer: A · Stay with him in a calm, quiet place and reassure him that the effects are from the drug and will pass
Why this is the answer
For a frightening hallucinogen experience, a calm setting, a supportive person and simple reassurance usually help. The nurse also monitors vital signs and watches for injury or other substances.
Answer
A · Stay with him in a calm, quiet place and reassure him that the effects are from the drug and will pass
24.Mental health nursing
Answer: C · Mind reading; ask what other reasons there might be for the boss's behaviour
Why this is the answer
Mind reading is assuming others' thoughts without evidence. Exploring alternative explanations, such as the boss being busy, helps the patient test the thought and reduce distress.
Answer
C · Mind reading; ask what other reasons there might be for the boss's behaviour
25.Nursing math & unit conversions
Answer: 18:05
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
6 PM → 6 + 12 = 18
Answer
18:05
Answer
18:05
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: D = 81 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 = 135·0.6 = 81 mg
Answer
D = 81 mg
28.Dosage calculations
Answer: W = 80 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Volume of stock
V₁ = 2·100/10 = 20 mL
Water to add
W = 100 − 20 = 80 mL
Answer
W = 80 mL
29.IV infusion rates
Answer: R = 10 gtt/min
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.
Time in minutes
8·60 = 480 min
Drip rate
R = 250·20/480 = 10.42 ≈ 10 gtt/min
Answer
R = 10 gtt/min
At the bedside you round to the nearest whole drop: 10 gtt/min.
30.IV infusion rates
Answer: D = 300 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 = 10·30 = 300 mg/h
Answer
D = 300 mg/h
31.Pediatric & critical-care dosing
Answer: R = 4.7 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
0.05·94 = 4.7 units/h
Concentration
250/250 = 1 units/mL
Pump rate
R = 4.7/1 = 4.7 mL/h
Answer
R = 4.7 mL/h
32.Pediatric & critical-care dosing
Answer: D = 17.9 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
500 000/250 = 2000 mcg/mL
Micrograms per minute
37·2000 = 74000 mcg/h
74000/60 = 1233 mcg/min
Per kilogram
D = 1233/69 = 17.87 ≈ 17.9 mcg/kg/min
Answer
D = 17.9 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 1.17 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
225 + 500 + 425 = 1150 mL
Per kilogram per hour
U = 1150/(82·12) = 1.169 ≈ 1.17 mL/kg/h
Answer
U = 1.17 mL/kg/h
34.IV fluids & fluid balance
Answer: V = 50 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
13:30 → 16:30 = 3 h
Volume infused
150·3 = 450 mL
Volume left
V = 500 − 450 = 50 mL
Answer
V = 50 mL
35.Clinical assessment scores
Answer: SI = 0.66
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 = 105/158 = 0.6646 ≈ 0.66
Answer
SI = 0.66
Within or below the usual 0.5–0.7.
36.Clinical assessment scores
Answer: very high risk
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: constantly moist → 1
activity: bedfast → 1
mobility: completely immobile → 1
nutrition: excellent → 4
friction and shear: problem → 1
Add
Braden total = 1 + 1 + 1 + 1 + 4 + 1 = 9
Risk level
9 → very high risk
Answer
very high risk
37.Arterial blood gas interpretation
Answer: fully compensated
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 7.37: within 7.35–7.45
PaCO₂ 25 mmHg: low (35–45)
HCO₃⁻ 14 mmol/L: low (22–26)
Compensation
Clinically, also check the expected compensation: Winter’s formula expects PaCO₂ 27–31 mmHg, so the measured 25 mmHg points to an additional respiratory alkalosis (a mixed disorder). The answer above is the ROME exam classification.
fully compensated
Answer
fully compensated
38.Arterial blood gas interpretation
Answer: added respiratory acidosis
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
1.5·17 + 8 = 33.5 → 31.5–35.5 mmHg
Compare
measured: 48 mmHg → added respiratory acidosis
Answer
added respiratory acidosis
39.ECG rhythm strip interpretation
Answer: QTc = 0.394 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 9 × 0.04 = 0.36 s
RR = 19 × 0.04 = 0.76 s
Fridericia’s formula
QTc = 0.36/∛0.76 = 0.36/0.9126 = 0.394 s
Answer
QTc = 0.394 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (394 ms)
40.ECG rhythm strip interpretation
Answer: torsades de pointes
More ventricular rhythms: torsades de pointes is a polymorphic ventricular tachycardia, usually 150–250/min, in which the wide complexes change in height and twist around the baseline, pointing up for a few beats and then down. Textbooks link it to a prolonged QT interval, and magnesium sulfate is the drug resuscitation guidelines name for it. An idioventricular rhythm is a ventricular escape rhythm: regular, wide QRS (0.12 s or more), no P waves, at 20–40/min (an accelerated idioventricular rhythm runs at 40–100/min). Monomorphic VT has identical wide complexes at more than 100/min. VF is chaotic, without any repeating complex.
Five steps
1. Rate: very fast, the complexes are about 7 small boxes apart (about 214 per minute).
2. Rhythm: fast and roughly regular, but the height and direction of the complexes change in a repeating spindle pattern.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: wide and polymorphic; the complexes twist around the baseline, pointing up for a few beats and then down.
Interpretation
torsades de pointes
Answer
torsades de pointes
Torsades de pointes is a polymorphic VT linked to a prolonged QT interval. This is identification practice only.
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