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
In which direction should a female patient's perineum be cleaned?
AIn circles starting at the anus
BEither way, as long as soap is used
CFrom back to front
DFrom front to back
2.Nursing fundamentalsHard
Which simple measure helps reduce the risk of delirium in an older inpatient?
ALimiting visits from family members
BKeeping the lights on all night
CMoving them to a different bed every night to vary their surroundings
DMaking sure they have their glasses and hearing aids
3.Infection control & patient safetyMedium
A small fire starts in a waste bin in a patient’s room while the patient is in bed. What does the nurse do first?
AOpen the windows to clear the smoke
BRemove the patient from immediate danger
CPhone the manager to report the fire
DGo and look for the nearest fire extinguisher
4.Infection control & patient safetyHard
A patient with a common cold asks for antibiotics “to be on the safe side”. Which response is best?
ASuggest using leftover antibiotics from a previous illness
BAsk the provider to prescribe antibiotics anyway so that the patient is reassured
CTell the patient that antibiotics will shorten the cold by several days
DExplain that antibiotics do not work on viruses and overuse breeds resistant bacteria
5.Prioritization & delegationMedium
After a hip replacement using a posterior approach, which statement shows a need for further teaching?
A“I will cross my legs when I sit, so I am more comfortable.”
B“I will keep a pillow between my knees when I lie on my side in bed.”
C“I will use a raised toilet seat at home.”
D“I will not bend my hip past 90 degrees.”
6.Prioritization & delegationHard
During START triage, an adult is not breathing. The airway is repositioned and the victim still does not breathe. What is the correct category?
ARed, because no breathing is the most urgent finding
BYellow, and come back later
CBlack (deceased or expectant)
DRed, and start CPR at once
7.Clinical nursingMedium
Why are older adults at higher risk of dehydration?
ATheir kidneys hold on to too much water
BTheir body water content increases with age
CThey always drink large amounts of tea
DTheir sense of thirst is often reduced
8.Clinical nursingHard
A patient on metformin with reduced kidney function is due a CT scan with IV contrast. Why might metformin be withheld?
AMetformin causes severe bleeding during scans
BThere is a risk of lactic acidosis if kidney function worsens
CMetformin reacts with the contrast to cause severe hyperglycaemia
DMetformin makes the images blurry
9.Lab values & electrolytesMedium
A patient on digoxin has a level of 2.8 ng/mL and a heart rate of 52/min. What is the nurse’s best action?
AGive the dose, as the heart rate is above 50/min
BGive a double dose to correct the rhythm
CHold the dose and inform the prescriber
DGive the dose and recheck the level in a month
10.Lab values & electrolytesHard
During an IV magnesium sulfate infusion, which assessment best detects toxicity early?
AKnee reflexes, respiratory rate and urine output
BBowel sounds and abdominal girth
CSkin color and capillary refill every hour
DBlood glucose and pupil size every hour
11.PharmacologyMedium
After naloxone reverses an opioid overdose, why must the patient be watched closely?
ANaloxone may wear off before the opioid does, so breathing can slow again
BNaloxone makes the opioid stay longer in the body
CNaloxone often causes severe low blood glucose a few hours after the dose
DNaloxone itself causes respiratory depression at high doses
12.PharmacologyHard
Why are patients on long-acting nitrates advised to have a nitrate-free period of several hours each day?
ATo reduce the risk of bleeding
BTo avoid nitrate accumulation in fat tissue
CTo prevent tolerance to the nitrate
DTo let the liver recover from toxicity
13.Med-surg: cardiovascular & respiratoryMedium
A patient is starting long-term amiodarone. Which teaching and monitoring are most important?
AEat extra salt and stop the drug as soon as the pulse is regular
BProtect skin from sunlight and have thyroid, liver and lung checks
CExpect orange urine and no need for blood tests
DAvoid dairy products and have the INR checked once at the start
14.Med-surg: cardiovascular & respiratoryHard
A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?
AStopping all medicines, including inhalers
BA low-dose opioid with a hand-held fan and calm positioning
CHigh-flow oxygen at 15 L/min whatever the oxygen saturation is
DEncouraging long walks to build fitness
15.Med-surg: neuro, endocrine & renalMedium
A patient on insulin asks about drinking alcohol. Which advice is correct?
AAlcohol raises glucose, so extra insulin should be taken first
BAlcohol should replace a meal on the days it is drunk
CAlcohol has no effect on blood glucose in people with diabetes
DAlcohol can cause hypos, even the next day, so eat carbs with it
16.Med-surg: neuro, endocrine & renalHard
A patient with hypopituitarism needs both hydrocortisone and levothyroxine. Which is usually started first?
ALevothyroxine
BBoth on the same day, in any order
CHydrocortisone
DNeither, until symptoms appear
17.Med-surg: GI, perioperative & oncologyMedium
Why are laxatives and enemas avoided when appendicitis is suspected?
AThey may increase the risk of perforation
BThey make the blood tests impossible to read
CThey always cause the appendix to bleed heavily
DThey stop antibiotics from being absorbed
18.Med-surg: GI, perioperative & oncologyHard
A patient with bone metastases is starting regular zoledronic acid. Which advice is important?
ATake extra calcium only on the day of infusion
BHave a dental check and report jaw pain or loose teeth
CAvoid all physical activity for six months
DStop drinking all fluids on the day of each infusion
19.Maternity & obstetric nursingMedium
Parents ask why their baby is having a pulse oximetry check on the right hand and a foot. What is the reason?
ATo screen for hearing loss
BTo measure the baby's blood pressure
CTo screen for critical congenital heart disease
DTo check the baby's blood glucose
20.Maternity & obstetric nursingHard
Shortly after an epidural is started, a labouring woman's blood pressure falls to 86/50 mmHg and the fetal heart rate drops. What should the nurse do first?
ATurn her onto her side to move the uterus off the large vessels
BIncrease the epidural infusion rate
CAsk her to walk around the room
DRaise the head of the bed to a high sitting position to improve her breathing
21.Pediatric nursingMedium
Which finding in a newborn suggests Hirschsprung disease?
AProjectile vomiting at 4 weeks
BA barking cough
CBright yellow, loose stools
DFailure to pass meconium within 48 hours of birth
22.Pediatric nursingHard
A toddler has burns on both feet and the buttocks, with sharp "stocking" lines and no splash marks. What should the nurse consider?
APossible deliberate immersion; follow the safeguarding procedure
BSunburn from playing outside in a paddling pool on a hot day
CAn accidental spill from a cup of tea
DA skin infection that looks like a burn
23.Mental health nursingMedium
A patient says, "I'm going to be a famous singer, and I'll buy this whole hospital." Which response best uses the technique of voicing doubt?
A"That sounds hard to believe."
B"Why do you want to buy the hospital?"
C"You know that isn't true at all."
D"That's wonderful. When will you start?"
24.Mental health nursingHard
A patient with PTSD suddenly appears terrified, staring and breathing quickly, and says she is "back there". What should the nurse do first?
AAsk her to describe every detail of the trauma straight away so that she can process the memory
BTouch her suddenly from behind to get her attention
CLeave the room so she can calm down alone
DSpeak calmly, use her name and use grounding techniques to bring her attention to the present
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.16586 mL. The rule in this exercise is that volumes below 1 mL are rounded to the nearest hundredth of a mL. What value x do you record?
0.16586 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 20:00 and finishes at 00:25 the next morning (24-hour clock). How many minutes t did it run?
20:0000:25
t = min
27.Dosage calculationsMedium
A patient weighs 60 kg. The prescribed dose is 10 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
60 kg10 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
You must prepare 500 mL of a 5% (w/v) solution from a 25% (w/v) stock solution. What volume of stock V₁ do you need?
C₁ = 25%C₂ = 5%V₂ = 500 mL
V₁ = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 12 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1500 mL12 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 50 gtt/min through a set of 60 gtt/mL. There are 300 mL left in the bag. How many hours t until it is empty?
50 gtt/min60 gtt/mL300 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 250 mL. The order is 0.1 units/kg/h for a patient who weighs 79 kg. Find the pump rate R in mL/h. Round to one decimal place.
100 units/250 mL0.1 units/kg/h79 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 31 mL/h. The patient weighs 103 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
500 mg/250 mL31 mL/h103 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 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL. Count ice chips as half their volume.
tea: 200 mLsoup: 150 mLice chips: 120 mLIV infusion: 125 mL/h × 8 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 06:00 and runs by pump at 100 mL/h. How many mL V are left in the bag at 10:00?
1000 mL100 mL/h06:00 → 10:00
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: no; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 20/min, SpO₂ 86% on room air, blood pressure 150/90 mmHg, pulse 64/min, alert, temperature 37.1 °C. Which clinical risk group does the patient fall into? Click it.
RR 20SpO₂ 86%airSBP 150HR 64AT 37.1 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.42, PaCO₂ 57 mmHg (7.6 kPa) and HCO₃⁻ 36 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.42PaCO₂ 57 mmHg (7.6 kPa)HCO₃⁻ 36 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 145, Cl⁻ 105, HCO₃⁻ 20 mmol/L and albumin 21 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
1sinus tachycardia
2atrial flutter, 4:1 conduction
3atrial flutter, 3:1 conduction
4atrial fibrillation
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
1atrial fibrillation
2atrial flutter, 2:1 conduction
3torsades de pointes
4ventricular tachycardia
3Solutions
1.Nursing fundamentals
Answer: D · From front to back
Why this is the answer
Cleaning from the urethra towards the anus moves bacteria away from the urinary tract and lowers the risk of urinary tract infection.
Answer
D · From front to back
2.Nursing fundamentals
Answer: D · Making sure they have their glasses and hearing aids
Why this is the answer
Sensory aids, orientation, good sleep, hydration, mobility and family involvement all help prevent delirium. Frequent moves and poor sleep make it more likely.
Answer
D · Making sure they have their glasses and hearing aids
3.Infection control & patient safety
Answer: B · Remove the patient from immediate danger
Why this is the answer
Rescue comes first: move the patient away from the fire. Then raise the alarm, contain the fire by closing doors, and extinguish it if safe. Opening windows feeds the fire with oxygen.
Answer
B · Remove the patient from immediate danger
4.Infection control & patient safety
Answer: D · Explain that antibiotics do not work on viruses and overuse breeds resistant bacteria
Why this is the answer
Colds are caused by viruses, which antibiotics do not kill. Unneeded antibiotics cause side effects and drive resistance, so the nurse explains this and offers advice on managing symptoms.
Answer
D · Explain that antibiotics do not work on viruses and overuse breeds resistant bacteria
5.Prioritization & delegation
Answer: A · “I will cross my legs when I sit, so I am more comfortable.”
Why this is the answer
After a posterior hip replacement, crossing the legs, bending the hip beyond 90 degrees and turning the leg inwards can cause dislocation. Raised seats and a pillow between the knees help prevent it.
Answer
A · “I will cross my legs when I sit, so I am more comfortable.”
6.Prioritization & delegation
Answer: C · Black (deceased or expectant)
Why this is the answer
In START, a victim who does not breathe after the airway is repositioned is tagged black. CPR for one person would take rescuers away from many others who could survive. If breathing starts after repositioning, the victim is red.
Answer
C · Black (deceased or expectant)
7.Clinical nursing
Answer: D · Their sense of thirst is often reduced
Why this is the answer
With age, thirst is blunted, kidney concentrating ability falls and total body water decreases. Cognitive or physical problems can also make it harder to drink.
Answer
D · Their sense of thirst is often reduced
8.Clinical nursing
Answer: B · There is a risk of lactic acidosis if kidney function worsens
Why this is the answer
Iodinated contrast can worsen kidney function, and metformin can then accumulate and cause lactic acidosis. Local policy guides when to stop and restart it.
Answer
B · There is a risk of lactic acidosis if kidney function worsens
9.Lab values & electrolytes
Answer: C · Hold the dose and inform the prescriber
Why this is the answer
A level of 2.8 ng/mL is above the usual range, and the slow heart rate fits toxicity. The nurse holds the dose, checks potassium and the ECG and informs the prescriber.
Answer
C · Hold the dose and inform the prescriber
10.Lab values & electrolytes
Answer: A · Knee reflexes, respiratory rate and urine output
Why this is the answer
Loss of the knee reflex is an early warning sign of magnesium toxicity and appears before slowed breathing. Magnesium is cleared by the kidneys, so falling urine output increases the risk. IV calcium gluconate counteracts magnesium toxicity.Checked against:Magnesium Toxicity · StatPearls (NCBI Bookshelf) (2026); Magnesium Toxicity · StatPearls (NCBI Bookshelf)
Answer
A · Knee reflexes, respiratory rate and urine output
11.Pharmacology
Answer: A · Naloxone may wear off before the opioid does, so breathing can slow again
Why this is the answer
Naloxone acts for a shorter time than many opioids, especially long-acting and slow-release ones. Repeated doses or an infusion may be needed.
Answer
A · Naloxone may wear off before the opioid does, so breathing can slow again
12.Pharmacology
Answer: C · To prevent tolerance to the nitrate
Why this is the answer
Tolerance to nitrates develops quickly with constant levels. An asymmetric dosing schedule or removing patches overnight keeps them effective.
Answer
C · To prevent tolerance to the nitrate
13.Med-surg: cardiovascular & respiratory
Answer: B · Protect skin from sunlight and have thyroid, liver and lung checks
Why this is the answer
Amiodarone causes photosensitivity, thyroid dysfunction (it contains iodine), liver toxicity, pulmonary fibrosis and corneal deposits. Patients use high-factor sunscreen and have regular thyroid and liver tests and reviews for cough or breathlessness. It also interacts with warfarin and digoxin.
Answer
B · Protect skin from sunlight and have thyroid, liver and lung checks
14.Med-surg: cardiovascular & respiratory
Answer: B · A low-dose opioid with a hand-held fan and calm positioning
Why this is the answer
Low-dose oral opioids can ease refractory breathlessness in advanced disease. A fan blowing air across the face, upright positioning, breathing techniques and anxiety management also help. Oxygen is used only if it relieves symptoms or corrects hypoxaemia.
Answer
B · A low-dose opioid with a hand-held fan and calm positioning
15.Med-surg: neuro, endocrine & renal
Answer: D · Alcohol can cause hypos, even the next day, so eat carbs with it
Why this is the answer
Alcohol reduces the liver's release of glucose, so it increases the risk of hypoglycaemia, which may be delayed for many hours. Patients should eat carbohydrate, check glucose before bed and tell friends that a hypo can look like drunkenness.
Answer
D · Alcohol can cause hypos, even the next day, so eat carbs with it
16.Med-surg: neuro, endocrine & renal
Answer: C · Hydrocortisone
Why this is the answer
Starting thyroid replacement first increases metabolism and cortisol clearance and can trigger an adrenal crisis in a patient with low cortisol. Glucocorticoid replacement is started before levothyroxine.
Answer
C · Hydrocortisone
17.Med-surg: GI, perioperative & oncology
Answer: A · They may increase the risk of perforation
Why this is the answer
Stimulating peristalsis can raise pressure on an inflamed appendix and may lead to rupture and peritonitis. The patient is kept nil by mouth while awaiting surgical assessment.
Answer
A · They may increase the risk of perforation
18.Med-surg: GI, perioperative & oncology
Answer: B · Have a dental check and report jaw pain or loose teeth
Why this is the answer
Bisphosphonates can cause osteonecrosis of the jaw, especially after dental extractions. A dental check before starting, good oral hygiene and reporting jaw symptoms are advised. Kidney function and calcium are also monitored.
Answer
B · Have a dental check and report jaw pain or loose teeth
19.Maternity & obstetric nursing
Answer: C · To screen for critical congenital heart disease
Why this is the answer
Pulse oximetry screening compares oxygen saturation in the right hand (pre-ductal) and a foot (post-ductal). A low reading or a significant difference can indicate critical congenital heart disease.
Answer
C · To screen for critical congenital heart disease
20.Maternity & obstetric nursing
Answer: A · Turn her onto her side to move the uterus off the large vessels
Why this is the answer
A lateral position relieves aortocaval compression and improves venous return and placental flow. Then increase IV fluids as ordered, notify the anaesthetist or provider and give a vasopressor if prescribed.
Answer
A · Turn her onto her side to move the uterus off the large vessels
21.Pediatric nursing
Answer: D · Failure to pass meconium within 48 hours of birth
Why this is the answer
Delayed passage of meconium, abdominal distension and bilious vomiting suggest Hirschsprung disease. Older children may have chronic constipation and ribbon-like stools.
Answer
D · Failure to pass meconium within 48 hours of birth
22.Pediatric nursing
Answer: A · Possible deliberate immersion; follow the safeguarding procedure
Why this is the answer
Symmetrical burns with clear edges on the feet, hands or buttocks, without splash marks, suggest forced immersion in hot water. The nurse documents the findings accurately and follows local safeguarding procedures.
Answer
A · Possible deliberate immersion; follow the safeguarding procedure
23.Mental health nursing
Answer: A · "That sounds hard to believe."
Why this is the answer
Voicing doubt lets the patient know the nurse does not share the belief, without a confrontation. Arguing tends to make delusional beliefs firmer, while agreeing reinforces them.
Answer
A · "That sounds hard to believe."
24.Mental health nursing
Answer: D · Speak calmly, use her name and use grounding techniques to bring her attention to the present
Why this is the answer
During a flashback, grounding (orienting to the present, using the senses, calm reassurance) helps the patient regain contact with reality. Detailed trauma work belongs in planned therapy, and sudden touch can be frightening.
Answer
D · Speak calmly, use her name and use grounding techniques to bring her attention to the present
25.Nursing math & unit conversions
Answer: x = 0.17 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the hundredths place
0.16586 → 6
Only the next digit decides
0.16586 → 5
5 is 5 or more, so round 6 up.
The digits after it (86) are ignored: round once, never step by step.
Round
x = 0.17 mL
Answer
x = 0.17 mL
26.Nursing math & unit conversions
Answer: t = 265 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
20:00 → 24:00 = 240 min
After midnight
00:00 → 00:25 = 25 min
Total
t = 240 + 25 = 265 min
Answer
t = 265 min
27.Dosage calculations
Answer: D = 300 mg
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.
Total per day
10·60 = 600 mg
Per dose
D = 600/2 = 300 mg
Answer
D = 300 mg
28.Dosage calculations
Answer: V₁ = 100 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 = 5·500/25 = 100 mL
Answer
V₁ = 100 mL
29.IV infusion rates
Answer: R = 21 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
12·60 = 720 min
Drip rate
R = 1500·10/720 = 20.83 ≈ 21 gtt/min
Answer
R = 21 gtt/min
At the bedside you round to the nearest whole drop: 21 gtt/min.
30.IV infusion rates
Answer: t = 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
50·60/60 = 50 mL/h
Time left
t = 300/50 = 6 h
Answer
t = 6 h
31.Pediatric & critical-care dosing
Answer: R = 19.8 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.
Units per hour
0.1·79 = 7.9 units/h
Concentration
100/250 = 0.4 units/mL
Pump rate
R = 7.9/0.4 = 19.75 ≈ 19.8 mL/h
Answer
R = 19.8 mL/h
32.Pediatric & critical-care dosing
Answer: D = 10 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
31·2000 = 62000 mcg/h
62000/60 = 1033 mcg/min
Per kilogram
D = 1033/103 = 10.03 ≈ 10 mcg/kg/min
Answer
D = 10 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 1510 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Add the intake
oral: 200 + 150 = 350 mL
ice chips: 120/2 = 60 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 1·100 = 100 mL
I = 1510 mL
Answer
I = 1510 mL
34.IV fluids & fluid balance
Answer: V = 600 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
06:00 → 10:00 = 4 h
Volume infused
100·4 = 400 mL
Volume left
V = 1000 − 400 = 600 mL
Answer
V = 600 mL
35.Clinical assessment scores
Answer: MFS = 35
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: no → 0
secondary diagnosis: no → 0
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: yes → 20
gait: normal, bed rest or wheelchair → 0
mental status: knows own limits → 0
Add
Morse total = 0 + 0 + 15 + 20 + 0 + 0 = 35
Answer
MFS = 35
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 20/min → 0
SpO₂ 86% → 3
on air → 0
SBP 150 mmHg → 0
HR 64/min → 0
alert (A) → 0
T 37.1 °C → 0
Total and red scores
NEWS2 = 0 + 3 + 0 + 0 + 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: 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 7.42: within 7.35–7.45
PaCO₂ 57 mmHg: high (35–45)
HCO₃⁻ 36 mmol/L: high (22–26)
Compensation
Clinically, also check the expected compensation: for a metabolic alkalosis PaCO₂ ≈ 0.7·HCO₃⁻ + 21 = 44.2–48.2 mmHg, so the measured 57 mmHg points to an additional respiratory acidosis (a mixed disorder). The answer above is the ROME exam classification.
fully compensated
Answer
fully compensated
38.Arterial blood gas interpretation
Answer: AGc = 24.75 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 = 145 − (105 + 20) = 20
Correction for albumin
20 + 0.25·(40 − 21) = 24.75 mmol/L
Answer
AGc = 24.75 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: atrial flutter, 4:1 conduction
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: R–R = 20 small boxes, 1500 ÷ 20 ≈ 75 per minute.
2. Rhythm: regular, every R–R is 0.80 s.
3. P waves: none; regular sawtooth flutter waves every 0.20 s (300 per minute), 4 for each QRS.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
atrial flutter, 4:1 conduction
Answer
atrial flutter, 4:1 conduction
40.ECG rhythm strip interpretation
Answer: ventricular tachycardia
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
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 identifiable.
4. PR interval: not measurable.
5. QRS: 0.14 s, wide (0.12 s or more).
Interpretation
ventricular tachycardia
Answer
ventricular tachycardia
In resuscitation guidelines VF and pulseless VT are the shockable rhythms. This is identification practice only.
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