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 should adhesive tape be removed from an older patient's fragile skin?
AAfter wetting it with alcohol rub
BBy pulling it away from the wound as hard as possible
CQuickly in one firm pull, straight upwards and away from the skin
DSlowly, low and close to the skin, while supporting the skin
2.Nursing fundamentalsHard
A patient has been taught to walk with underarm crutches. Which statement shows a need for further teaching?
A"I'll rest my weight on the tops of the crutches under my arms."
B"I'll take my weight through my hands on the hand grips."
C"I'll keep the crutch tips about a step out to the side and front."
D"I'll check the rubber tips regularly for wear."
3.Infection control & patient safetyMedium
Which household item is a strangulation risk for young children?
AA plastic picture book
BLooped cords on window blinds
CA large wooden building block
DSoft cotton socks
4.Infection control & patient safetyHard
A nurse observes a colleague going from one patient to the next without hand hygiene. What is the best action?
ARemind the colleague politely at once
BWait to see whether the colleague does it next time
CSay nothing, to avoid conflict within the team
DReport it anonymously to the manager a month later
5.Prioritization & delegationMedium
A patient has a new plaster cast that is still drying. How should the nurse handle it?
ABy covering it tightly with a plastic sheet
BWith the palms of the hands, not the fingertips
CBy resting it directly on a hard surface
DWith the fingertips, pressing firmly to test it
6.Prioritization & delegationHard
During JumpSTART triage, a child who cannot walk is breathing 50 times a minute. Which category is the child given?
AGreen (minor)
BRed (immediate)
CBlack (expectant)
DYellow (delayed)
7.Clinical nursingMedium
The WHO analgesic ladder recommends:
AGiving analgesia only when pain becomes severe
BMoving from non-opioids to weak and then strong opioids as pain increases
CStarting all patients on strong opioids
DUsing only non-drug methods for cancer pain
8.Clinical nursingHard
Why is a patient kept under observation for several hours after successful treatment of anaphylaxis?
AAdrenaline always causes a heart attack hours later
BThe patient must stay until all allergy tests are complete
CSymptoms can return later in a biphasic reaction
DAntihistamines cause dangerous drowsiness for 24 hours
9.Lab values & electrolytesMedium
A patient with iron-deficiency anemia started oral iron. Which result is usually the earliest sign that treatment is working?
AA rise in the reticulocyte count
BA fall in the white cell count
CA fall in the mean cell volume (MCV)
DA rise in the platelet count
10.Lab values & electrolytesHard
The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?
A"I'll blow my nose gently, not forcefully"
B"I'll use an electric razor to shave"
C"I'll use a soft-bristled toothbrush"
D"I'll take aspirin if I get a headache"
11.PharmacologyMedium
Which assessment is most important before giving a dose of IV morphine?
ARespiratory rate and level of sedation
BBlood glucose and temperature, checked before each dose
CBowel sounds and urine colour
DPupil size and hearing
12.PharmacologyHard
A patient with type 2 diabetes starts a high dose of prednisolone for a flare of COPD. Which change should the nurse expect?
ANo change in glucose, as steroids act only in the lungs
BLower potassium only, with no effect on glucose
CHigher blood glucose, so more frequent glucose checks are needed
DLower blood glucose, so the diabetes medicines should be stopped
13.Med-surg: cardiovascular & respiratoryMedium
A patient who has just started an antihypertensive feels dizzy when getting out of bed. What is the correct advice?
AStand up quickly so the blood keeps moving
BStop taking the tablet without telling the doctor or nurse
CTake a double dose the next morning instead
DSit on the bed edge for a moment before standing
14.Med-surg: cardiovascular & respiratoryHard
An 84-year-old with heart failure becomes breathless with new crackles and a rising blood pressure during a blood transfusion. What should the nurse suspect?
AAn acute haemolytic reaction from wrong blood
BA mild febrile reaction
CTransfusion-associated circulatory overload
DNormal effects of the transfusion
15.Med-surg: neuro, endocrine & renalMedium
A patient with SIADH has a sodium of 126 mmol/L and mild symptoms. Which treatment is usually first-line?
AFluid restriction
BExtra oral water
CIV 5% glucose infusion
DDesmopressin
16.Med-surg: neuro, endocrine & renalHard
The nurse has four neurology patients. Which one needs to be seen first?
AA patient with Parkinson's disease whose next dose is due in one hour
BA patient with a headache after a lumbar puncture this morning
CA patient with Guillain–Barré syndrome whose vital capacity is falling
DA patient with multiple sclerosis who is tired after physiotherapy
17.Med-surg: GI, perioperative & oncologyMedium
Which advice has good evidence for reducing cancer-related fatigue?
AAvoiding all daily activities
BComplete bed rest for the whole course of treatment
CDrinking several strong coffees every evening
DRegular light to moderate activity, such as walking
18.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient after a colonoscopy with polyp removal. Which statement shows a need for further teaching?
A"I'll report heavy bleeding from my bottom."
B"I should report a fever or a swollen, painful abdomen."
C"Some wind and bloating today is expected."
D"Severe abdominal pain is normal for a week afterwards."
19.Maternity & obstetric nursingMedium
Which substance in amniotic fluid is used to judge fetal lung maturity?
AAlpha-fetoprotein, assessed by its level
BSurfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
CBilirubin, assessed by its colour
DGlucose, assessed by its concentration
20.Maternity & obstetric nursingHard
A woman has had a large postpartum haemorrhage and is receiving several units of blood. Which other complication should the nurse watch for?
AHypertension caused by the volume of blood lost
BPostpartum depression within the hour
CHypoglycaemia from the transfused blood
DCoagulopathy from loss of clotting factors
21.Pediatric nursingMedium
Which defect classically causes a continuous "machinery" murmur?
APatent ductus arteriosus
BAtrial septal defect
CIsolated pulmonary stenosis with an intact ventricular septum
DTetralogy of Fallot
22.Pediatric nursingHard
A child treated with intravenous immunoglobulin (IVIG) for Kawasaki disease is due her MMR vaccine next week. What should the nurse know?
AMMR should be given early, because IVIG weakens the immune system
BLive vaccines are usually delayed for several months after IVIG
CMMR can be given safely the same day as the next IVIG dose
DIVIG makes vaccines unnecessary, so MMR can be skipped
23.Mental health nursingMedium
Which finding in a patient with anorexia nervosa is most concerning?
AFeeling cold in a warm room
BA resting heart rate of 38/min
CConstipation for the past few days
DDry skin and brittle hair
24.Mental health nursingHard
Three weeks after her husband died, a woman says she sometimes briefly hears him call her name at home. She is otherwise eating, sleeping and coping. How should the nurse interpret this?
AIt is a sign of schizophrenia that needs antipsychotic medicine
BIt means she has delirium and needs urgent tests
CIt proves she has severe major depression with psychosis
DBrief experiences like this can be part of normal grief
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 12:00 PM. Which entry is the same time on the 24-hour clock? Click it.
12:00 PM
100:00
212:00
313:00
424:00
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A haemoglobin result is 10.2 g/dL. Express it in g/L Hb.
10.2 g/dL1 L = 10 dL
Hb = g/L
27.Dosage calculationsMedium
A child weighing 34 kg is prescribed 2 mg/kg of a drug. The stock solution contains 10 mg/mL. Draw up the dose: what volume V do you give?
34 kg2 mg/kg10 mg/mL
V = mL
28.Dosage calculationsHard
A patient weighs 118.8 lb. The prescription is 15 mg/kg as a single dose, and the stock contains 200 mg in 5 mL. Using 1 kg = 2.2 lb, what volume V do you give? Round to one decimal place.
118.8 lb15 mg/kg200 mg/5 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 60 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
60 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 40 gtt/min through a set of 15 gtt/mL. There are 900 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
40 gtt/min15 gtt/mL900 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 500 mL. The order is 14 units/kg/h for a patient who weighs 64 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL14 units/kg/h64 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 800 mg in 500 mL. The order is 10 mcg/kg/min for a patient who weighs 78 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL10 mcg/kg/min78 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-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 runs by pump at 80 mL/h. At 20:00, 50 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL50 mL infused80 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 18/min, SpO₂ 96% on room air, blood pressure 130/78 mmHg, pulse 120/min, alert, temperature 37.9 °C. What is the NEWS2 total score?
RR 18SpO₂ 96%airSBP 130HR 120AT 37.9 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 116 kg and is 163 cm tall. Calculate the BMI and click the WHO weight category.
116 kg163 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 12 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 12 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 146, Cl⁻ 115, HCO₃⁻ 17 mmol/L and albumin 28 g/L. Find the albumin-corrected anion gap AGc = AG + 0.25·(40 − albumin).
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
1ventricular tachycardia
2sinus tachycardia
3supraventricular tachycardia (SVT)
4accelerated junctional rhythm
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
22:1 AV block (type undetermined)
3sinus bradycardia
4first-degree AV block
3Solutions
1.Nursing fundamentals
Answer: D · Slowly, low and close to the skin, while supporting the skin
Why this is the answer
Peeling the tape back low and slow while holding the skin reduces the pulling force on fragile skin. Adhesive removers can also help.
Answer
D · Slowly, low and close to the skin, while supporting the skin
2.Nursing fundamentals
Answer: A · "I'll rest my weight on the tops of the crutches under my arms."
Why this is the answer
Leaning on the armpits can damage the brachial plexus and cause crutch palsy. Weight is taken through the hands, with a gap of a few finger-widths between the crutch top and the armpit.
Answer
A · "I'll rest my weight on the tops of the crutches under my arms."
3.Infection control & patient safety
Answer: B · Looped cords on window blinds
Why this is the answer
Young children can become entangled in looped blind and curtain cords. Cordless blinds or cord tie-downs, and keeping cribs away from windows, prevent strangulation.
Answer
B · Looped cords on window blinds
4.Infection control & patient safety
Answer: A · Remind the colleague politely at once
Why this is the answer
Prompt, respectful reminders prevent harm to the next patient. Most hospitals encourage all staff to speak up about hand hygiene, and this is part of a safety culture.
Answer
A · Remind the colleague politely at once
5.Prioritization & delegation
Answer: B · With the palms of the hands, not the fingertips
Why this is the answer
A wet plaster cast can be dented by fingertips, causing pressure points under the cast. It is handled with the palms, supported on pillows and left uncovered to dry.
Answer
B · With the palms of the hands, not the fingertips
6.Prioritization & delegation
Answer: B · Red (immediate)
Why this is the answer
In JumpSTART, a respiratory rate below 15 or above 45 per minute makes the child immediate (red). Children breathe faster than adults, so the adult cut-off of 30 is not used.
Answer
B · Red (immediate)
7.Clinical nursing
Answer: B · Moving from non-opioids to weak and then strong opioids as pain increases
Why this is the answer
The ladder moves from non-opioids (such as paracetamol) to weak opioids and then strong opioids, with adjuvants at any step. Regular dosing is preferred for persistent pain.
Answer
B · Moving from non-opioids to weak and then strong opioids as pain increases
8.Clinical nursing
Answer: C · Symptoms can return later in a biphasic reaction
Why this is the answer
Some patients have a second wave of symptoms hours after the first, called a biphasic reaction. Observation, an adrenaline auto-injector where indicated and allergy referral are part of safe discharge.
Answer
C · Symptoms can return later in a biphasic reaction
9.Lab values & electrolytes
Answer: A · A rise in the reticulocyte count
Why this is the answer
Once iron is available, the marrow releases more young red cells, so the reticulocyte count rises within about 1–2 weeks. The hemoglobin rises more slowly over weeks, and iron stores take months to refill.Checked against:Reticulocyte Count · MedlinePlus (NIH) (2024)
Answer
A · A rise in the reticulocyte count
10.Lab values & electrolytes
Answer: D · "I'll take aspirin if I get a headache"
Why this is the answer
Aspirin irreversibly inhibits platelet function and raises the bleeding risk further in thrombocytopenia, so it and other NSAIDs are avoided unless prescribed. An electric razor, gentle nose blowing and a soft toothbrush reduce minor bleeding.Checked against:Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Aspirin · MedlinePlus (NIH) (2025)
Answer
D · "I'll take aspirin if I get a headache"
11.Pharmacology
Answer: A · Respiratory rate and level of sedation
Why this is the answer
Opioids can cause respiratory depression, which is usually preceded by increasing sedation. Both are checked before and after each dose.
Answer
A · Respiratory rate and level of sedation
12.Pharmacology
Answer: C · Higher blood glucose, so more frequent glucose checks are needed
Why this is the answer
Glucocorticoids raise blood glucose by increasing liver glucose production and insulin resistance. Glucose is monitored more often, and diabetes treatment may need to be increased during the course.
Answer
C · Higher blood glucose, so more frequent glucose checks are needed
13.Med-surg: cardiovascular & respiratory
Answer: D · Sit on the bed edge for a moment before standing
Why this is the answer
Postural (orthostatic) hypotension is common when starting antihypertensives. Changing position slowly reduces the risk of falls. Persistent symptoms should be reported so lying and standing blood pressures can be checked and the dose reviewed.
Answer
D · Sit on the bed edge for a moment before standing
14.Med-surg: cardiovascular & respiratory
Answer: C · Transfusion-associated circulatory overload
Why this is the answer
Transfusion-associated circulatory overload causes breathlessness, crackles, raised BP and JVP during or soon after transfusion, especially in older people and those with heart or kidney disease. The transfusion is stopped or slowed, the patient sat up and given oxygen, and diuretics may be prescribed. Slow rates and single units with reassessment reduce the risk.
Answer
C · Transfusion-associated circulatory overload
15.Med-surg: neuro, endocrine & renal
Answer: A · Fluid restriction
Why this is the answer
In SIADH the body retains water. Fluid restriction is the first-line treatment for mild to moderate cases, along with treating the cause. Hypotonic fluids and desmopressin would lower sodium further. Severe symptoms (seizures, reduced consciousness) need hypertonic saline in a monitored setting.
Answer
A · Fluid restriction
16.Med-surg: neuro, endocrine & renal
Answer: C · A patient with Guillain–Barré syndrome whose vital capacity is falling
Why this is the answer
A falling vital capacity and weak cough in Guillain–Barré syndrome warn of respiratory failure, which may need ventilation. The other patients have expected or less urgent problems.
Answer
C · A patient with Guillain–Barré syndrome whose vital capacity is falling
17.Med-surg: GI, perioperative & oncology
Answer: D · Regular light to moderate activity, such as walking
Why this is the answer
Exercise, matched to ability, reduces cancer-related fatigue. Pacing, prioritising activities, sleep routines and treating causes such as anaemia or depression also help.
Answer
D · Regular light to moderate activity, such as walking
18.Med-surg: GI, perioperative & oncology
Answer: D · "Severe abdominal pain is normal for a week afterwards."
Why this is the answer
Mild bloating and cramps from the air used are expected. Severe or worsening pain, fever, a distended abdomen or heavy rectal bleeding can mean perforation or haemorrhage and must be reported straight away.
Answer
D · "Severe abdominal pain is normal for a week afterwards."
19.Maternity & obstetric nursing
Answer: B · Surfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
Why this is the answer
Surfactant reduces surface tension and keeps alveoli open. An L/S ratio of about 2:1 or more suggests the lungs are mature. Amniotic fluid testing for lung maturity is now rarely used in practice.
Answer
B · Surfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
20.Maternity & obstetric nursing
Answer: D · Coagulopathy from loss of clotting factors
Why this is the answer
Massive haemorrhage and transfusion of red cells can deplete clotting factors and platelets, leading to further bleeding. Massive transfusion protocols include plasma, platelets and sometimes fibrinogen.
Answer
D · Coagulopathy from loss of clotting factors
21.Pediatric nursing
Answer: A · Patent ductus arteriosus
Why this is the answer
In a patent ductus arteriosus, blood flows from the aorta to the pulmonary artery throughout the cardiac cycle because aortic pressure is always higher. This produces a continuous, machinery-like murmur.
Answer
A · Patent ductus arteriosus
22.Pediatric nursing
Answer: B · Live vaccines are usually delayed for several months after IVIG
Why this is the answer
Antibodies in IVIG can neutralise live vaccine viruses and stop the vaccine from working, so MMR and varicella are usually postponed for several months (often about 11 months) after high-dose IVIG. Inactivated vaccines are not affected in the same way.
Answer
B · Live vaccines are usually delayed for several months after IVIG
23.Mental health nursing
Answer: B · A resting heart rate of 38/min
Why this is the answer
Severe bradycardia suggests cardiovascular compromise from starvation and can lead to dangerous arrhythmias. It is a common reason for urgent medical admission.
Answer
B · A resting heart rate of 38/min
24.Mental health nursing
Answer: D · Brief experiences like this can be part of normal grief
Why this is the answer
Briefly hearing or sensing the deceased is common in bereavement and is not usually a sign of mental illness. The nurse listens, normalises the experience and watches for signs of more complicated grief or depression.
Answer
D · Brief experiences like this can be part of normal grief
25.Nursing math & unit conversions
Answer: 12:00
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
12 PM → 12
Answer
12:00
Answer
12:00
26.Nursing math & unit conversions
Answer: Hb = 102 g/L
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.
Convert
Hb = 10.2 g/dL × 10 dL/L = 102 g/L
Answer
Hb = 102 g/L
27.Dosage calculations
Answer: V = 6.8 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 2·34 = 68 mg
Volume
V = 68/10 = 6.8 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 6.8 mL
28.Dosage calculations
Answer: V = 20.3 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
118.8/2.2 = 54 kg
Dose
15·54 = 810 mg
Volume
V = (810/200)·5 = 20.25 ≈ 20.3 mL
Answer
V = 20.3 mL
29.IV infusion rates
Answer: R = 60 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.
Millilitres per minute
60/60 = 1 mL/min
Drip rate
R = 1·60 = 60 gtt/min
Answer
R = 60 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: t = 5.6 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
40·60/15 = 160 mL/h
Time left
t = 900/160 = 5.625 ≈ 5.6 h
Answer
t = 5.6 h
31.Pediatric & critical-care dosing
Answer: R = 17.9 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
14·64 = 896 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 896/50 = 17.92 ≈ 17.9 mL/h
Answer
R = 17.9 mL/h
32.Pediatric & critical-care dosing
Answer: R = 29.3 mL/h
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 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
10·78 = 780 mcg/min
780·60 = 46800 mcg/h
Pump rate
R = 46800/1600 = 29.25 ≈ 29.3 mL/h
Answer
R = 29.3 mL/h
33.IV fluids & fluid balance
Answer: U = 1.33 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
350 + 325 + 200 = 875 mL
Per kilogram per hour
U = 875/(82·8) = 1.334 ≈ 1.33 mL/kg/h
Answer
U = 1.33 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 5.6 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
500 − 50 = 450 mL
Time
t = 450/80 = 5.625 ≈ 5.6 h
Answer
t = 5.6 h
That is about 5 h 38 min, so the bag runs out at about 01:38.
35.Clinical assessment scores
Answer: NEWS2 = 2
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 18/min → 0
SpO₂ 96% → 0
on air → 0
SBP 130 mmHg → 0
HR 120/min → 2
alert (A) → 0
T 37.9 °C → 0
Add
NEWS2 = 0 + 0 + 0 + 0 + 2 + 0 + 0 = 2
Answer
NEWS2 = 2
36.Clinical assessment scores
Answer: obesity class III
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 116/1.63² = 43.66
Category
obesity class III
Answer
obesity class III
37.Arterial blood gas interpretation
Answer: PaCO₂ = 26 mmHg
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.
Winter’s formula
PaCO₂ = 1.5·12 + 8 = 26 mmHg
range: 24–28 mmHg
Answer
PaCO₂ = 26 mmHg
38.Arterial blood gas interpretation
Answer: AGc = 17 mmol/L
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Anion gap
AG = 146 − (115 + 17) = 14
Correction for albumin
14 + 0.25·(40 − 28) = 17 mmol/L
Answer
AGc = 17 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: supraventricular tachycardia (SVT)
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. Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Five steps
1. Rate: R–R = 10 small boxes, 1500 ÷ 10 ≈ 150 per minute.
2. Rhythm: regular, every R–R is 0.40 s.
3. P waves: none visible; at this rate they are hidden in the QRS complexes or the T waves.
4. PR interval: not measurable.
5. QRS: 0.06 s, narrow (below 0.12 s), so the rhythm starts above the ventricles.
Interpretation
supraventricular tachycardia (SVT)
Answer
supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretation
Answer: 2:1 AV block (type undetermined)
2:1 AV block: with two P waves for every QRS, no two conducted P waves follow each other, so you cannot see whether the PR would lengthen (type I) or stay constant (type II) before a non-conducted P wave. From one strip it is called a 2:1 AV block; a longer strip or a change in the conduction ratio decides the type. A narrow QRS makes type I more likely and a wide QRS type II, but neither proves it.
Five steps
1. Rate: R–R = 44 small boxes, 1500 ÷ 44 ≈ 34 per minute.
2. Rhythm: regular, every R–R is 1.76 s.
3. P waves: upright and regular (P–P 0.88 s, 68 per minute), two for every QRS.
4. PR interval: constant at 0.18 s in the conducted beats.
5. QRS: 0.14 s, wide (0.12 s or more).
Why the type stays open
Every second P wave is not conducted, so no two conducted beats follow each other and a lengthening PR could never show.
2:1 AV block (type undetermined)
Answer
2:1 AV block (type undetermined)
A narrow QRS makes type I more likely and a wide QRS type II, but only a longer strip or a change in the conduction ratio decides.
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