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 England and Wales, what does it mean if a child under 16 is "Gillick competent"?
ATheir parents must always make every decision for them
BThey are old enough to vote and drive
CThey can refuse all treatment, whatever the risk, until they reach the age of 18
DThey have enough understanding to consent to a particular treatment themselves
2.Nursing fundamentalsHard
A patient with dementia keeps getting out of bed at night. What is the best first nursing approach?
AAsk the doctor to prescribe a sedative so the patient sleeps through the night
BRaise the bed rails and leave the patient alone
CLook for an unmet need such as toileting, pain, hunger or thirst
DTie a sheet across the bed to keep the patient in
3.Infection control & patient safetyMedium
Hair must be removed from a planned surgical site. Which method reduces the risk of surgical site infection?
AShaving with a razor just before the incision
BClipping with electric clippers just before surgery
CShaving with a disposable razor the night before surgery
DUsing wax strips on the morning of surgery
4.Infection control & patient safetyHard
During a power cut in a US hospital, a ventilator must stay powered. Where should it be plugged in?
AInto any white outlet in the room
BInto the outlet that is closest to the bed, whatever its color
CInto an extension cord from the corridor
DInto a red outlet connected to the emergency generator
5.Prioritization & delegationMedium
A patient has a nasogastric tube on suction. Which task can the nurse delegate to a nursing assistant?
AChecking the tube’s position
BAssessing the drainage for blood
CGiving mouth care
DIrrigating the tube when it blocks
6.Prioritization & delegationHard
During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?
AContinue the infusion, because headache is expected
BStop the infusion and inform the provider at once
CSlow the infusion and give an antiemetic as prescribed
DGive a dose of aspirin for the headache
7.Clinical nursingMedium
What does HbA1c measure?
AThe amount of ketones in the urine
BInsulin levels after a meal
CAverage blood glucose over roughly the previous two to three months
DBlood glucose at the moment of testing
8.Clinical nursingHard
A day after surgery, a patient's haemoglobin has fallen from 125 g/L to 85 g/L (12.5 to 8.5 g/dL) and their heart rate has risen to 118/min. What is the priority?
AEncourage the patient to eat iron-rich foods
BEscalate urgently, as the patient may be bleeding
CDocument the result and take no further action
DRecheck the haemoglobin next week
9.Lab values & electrolytesMedium
A patient has an absolute neutrophil count of 0.4 × 10³/µL. Which measure is appropriate?
AStrict hand hygiene, temperature checks and no visitors with infections
BTaking temperatures rectally because readings are more accurate
CBringing fresh flowers into the room to lift the patient’s mood
DSharing a room with another patient who is being treated for pneumonia
10.Lab values & electrolytesHard
A patient has taken metformin for 8 years and now has numbness in the feet, a hemoglobin of 10.2 g/dL (102 g/L) and an MCV of 108 fL. Which deficiency is most likely?
AIron deficiency from gut loss
BVitamin K deficiency
CVitamin D (calciferol) deficiency
DVitamin B12 deficiency
11.PharmacologyMedium
Why should a patient rinse the mouth after using an inhaled corticosteroid?
ATo reduce the risk of oral thrush (candidiasis) and hoarseness
BTo make the drug work faster in the lungs
CTo stop the drug being absorbed too quickly into the blood
DTo prevent a fall in blood glucose
12.PharmacologyHard
A patient with early aspirin (salicylate) overdose has tinnitus and is breathing fast. Which acid–base pattern is classic?
AMetabolic alkalosis followed by respiratory acidosis
BRespiratory alkalosis followed by metabolic acidosis
CPure metabolic alkalosis
DRespiratory acidosis with normal bicarbonate
13.Med-surg: cardiovascular & respiratoryMedium
How is the jugular venous pressure usually assessed?
APatient reclined at 45° with the head turned slightly to the left
BPatient sitting upright with the arms raised above the head
CPatient lying completely flat with the head turned to the right
DPatient standing with the neck flexed forward
14.Med-surg: cardiovascular & respiratoryHard
Two adults with cystic fibrosis are admitted to the same ward. What is the correct infection-control plan?
ALet them share physiotherapy sessions and equipment
BPut them in the same bay so they can support each other
CUse standard precautions only, as CF is not infectious
DNurse them in separate single rooms and keep them apart
15.Med-surg: neuro, endocrine & renalMedium
Which statement about long-acting basal insulin such as glargine is correct?
AIt is given only after large meals to cover the carbohydrate
BIt is mixed with rapid-acting insulin in the same syringe
CIn type 1 diabetes it is continued even when the patient is not eating
DIt has a sharp peak in action about 30 minutes after injection
16.Med-surg: neuro, endocrine & renalHard
Two days after surgery, an 80-year-old woman is quiet, sleepy, slow to answer and eating little. Her daughter says she is "not herself". What should the nurse suspect?
ANormal tiredness after an operation
BHypoactive delirium
CThe start of Alzheimer's disease
DSimple low mood about being in hospital
17.Med-surg: GI, perioperative & oncologyMedium
Why does a patient need lifelong vitamin B12 injections after total gastrectomy?
AVitamin B12 is lost in the urine after the surgery
BThe small bowel stops absorbing all nutrients
CIntrinsic factor from the stomach is no longer made
DThe liver can no longer store any vitamins
18.Med-surg: GI, perioperative & oncologyHard
Four patients are on a gastroenterology ward. Which should the nurse see first?
AA patient with an ileostomy waiting to change the pouch
BA patient with GORD who wants an antacid
CA patient with cirrhosis who is newly confused and drowsy
DA patient with stable ulcerative colitis asking about diet
19.Maternity & obstetric nursingMedium
Why is indomethacin generally not used as a tocolytic after about 32 weeks?
AIt can close the fetal ductus arteriosus too early
BIt causes severe maternal hypertension
CIt stimulates stronger contractions late in pregnancy
DIt triggers maternal hypoglycaemia
20.Maternity & obstetric nursingHard
A woman at 26 weeks has a haemoglobin of 95 g/L (9.5 g/dL) and a low ferritin. She is already taking oral iron but has severe side effects. What might be considered?
AStopping iron and waiting until after birth
BIntravenous iron
CA routine blood transfusion
DDoubling her caffeine intake
21.Pediatric nursingMedium
A child is receiving IV morphine. Which assessments are most important?
APeak flow and inhaler technique
BHead circumference and fontanelle tension
CBlood glucose and urine ketones
DRespiratory rate and level of sedation
22.Pediatric nursingHard
A 12-year-old with asthma has been prescribed a preventer inhaler (inhaled corticosteroid) to take every day. Which statement shows a need for further teaching?
A"I rinse my mouth after using my preventer inhaler."
B"I carry my reliever inhaler with me everywhere I go."
C"I use my spacer with my inhaler, even at school."
D"I stop taking my preventer inhaler whenever I've had a few good days."
23.Mental health nursingMedium
The wife of a man with alcohol dependence organises her life around his drinking, hides it from others and neglects her own needs. What does this pattern suggest?
ACodependency
BDelirium tremens
CLearned helplessness in the patient
DEnabling by the healthcare team
24.Mental health nursingHard
An 8-year-old with separation anxiety disorder has missed two weeks of school. What is the most helpful approach?
ALet a parent stay with him in class every day for the rest of the year
BAllow him to stay at home until he wants to go back
CTell him that he is being silly and must go
DSupport a gradual, planned return to school with a consistent goodbye routine
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 171 cm tall. Using 1 in = 2.54 cm, find the height h in inches. Round to one decimal place.
171 cm1 in = 2.54 cm
h = in
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A blood glucose result is 14.7 mmol/L. Using 1 mmol/L = 18 mg/dL for glucose, find c in mg/dL to the nearest whole number.
14.7 mmol/L1 mmol/L = 18 mg/dL
c = mg/dL
27.Dosage calculationsMedium
An ampoule of epinephrine (adrenaline) is labelled 1:1000 (1 mg/mL). The prescription is 0.3 mg IM for anaphylaxis. What volume V do you draw up?
1:10000.3 mg
V = mL
28.Dosage calculationsHard
A patient is 154 cm tall and weighs 64 kg. The prescription is 60 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
154 cm64 kg60 mg/m²
D = mg
29.IV infusion ratesMedium
Infuse 500 mL over 3 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL3 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 250 mg of a drug in 50 mL and runs at 10 mL/h. How many milligrams per hour D does the patient receive?
250 mg/50 mL10 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 60 units/kg for a patient who weighs 82 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
60 units/kg82 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 5 mcg/kg/min for a patient who weighs 55 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL5 mcg/kg/min55 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 IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 11:15 and runs by pump at 60 mL/h. How many mL V are left in the bag at 13:45?
500 mL60 mL/h11:15 → 13:45
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 9, with E2 and V4. What motor score M was recorded, and which response does it describe? Give the number.
GCS 9E2V4
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 69 kg and is 155 cm tall. Calculate the BMI and click the WHO weight category.
69 kg155 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.59, PaCO₂ 26 mmHg (3.5 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory alkalosis. How far is it compensated? Click your answer.
pH 7.59PaCO₂ 26 mmHg (3.5 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 136, Cl⁻ 105, HCO₃⁻ 18 mmol/L and albumin 18 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 arrhythmia
2second-degree AV block type II
3sinus bradycardia
4sinus rhythm with sinus arrest
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
1ventricular tachycardia
2atrial fibrillation
3atrial flutter, 2:1 conduction
4torsades de pointes
3Solutions
1.Nursing fundamentals
Answer: D · They have enough understanding to consent to a particular treatment themselves
Why this is the answer
A Gillick-competent young person under 16 has enough maturity and understanding to consent to a specific treatment. Competence is judged for each decision.
Answer
D · They have enough understanding to consent to a particular treatment themselves
2.Nursing fundamentals
Answer: C · Look for an unmet need such as toileting, pain, hunger or thirst
Why this is the answer
Restlessness in dementia often has a cause, such as needing the toilet, pain or being cold. Meeting the need is safer than restraint or sedation, which increase the risk of harm.
Answer
C · Look for an unmet need such as toileting, pain, hunger or thirst
3.Infection control & patient safety
Answer: B · Clipping with electric clippers just before surgery
Why this is the answer
Razors cause tiny skin cuts that bacteria can colonize, which raises the infection risk. If hair must be removed, clippers are used close to the time of surgery.
Answer
B · Clipping with electric clippers just before surgery
4.Infection control & patient safety
Answer: D · Into a red outlet connected to the emergency generator
Why this is the answer
In US hospitals, red outlets are usually connected to the emergency generator. Life-support equipment is plugged into them, and battery backups are checked as part of emergency planning.
Answer
D · Into a red outlet connected to the emergency generator
5.Prioritization & delegation
Answer: C · Giving mouth care
Why this is the answer
Mouth care is routine and important because the patient cannot eat or drink. Checking position, irrigating the tube and assessing drainage need nursing skills and judgement.
Answer
C · Giving mouth care
6.Prioritization & delegation
Answer: B · Stop the infusion and inform the provider at once
Why this is the answer
A new severe headache, vomiting or neurological decline during thrombolysis can mean intracranial bleeding. The infusion is stopped, the provider informed and an urgent scan arranged.
Answer
B · Stop the infusion and inform the provider at once
7.Clinical nursing
Answer: C · Average blood glucose over roughly the previous two to three months
Why this is the answer
HbA1c reflects glycation of haemoglobin over the life of red cells, giving an estimate of long-term glucose control.
Answer
C · Average blood glucose over roughly the previous two to three months
8.Clinical nursing
Answer: B · Escalate urgently, as the patient may be bleeding
Why this is the answer
A large fall in haemoglobin with tachycardia suggests ongoing blood loss. The nurse assesses the patient with ABCDE, checks wounds and drains and escalates for urgent review.
Answer
B · Escalate urgently, as the patient may be bleeding
9.Lab values & electrolytes
Answer: A · Strict hand hygiene, temperature checks and no visitors with infections
Why this is the answer
Severe neutropenia carries a high risk of infection. Hand hygiene, early recognition of fever and protection from sources of infection are key. Flowers can carry organisms, rectal procedures can injure the mucosa, and a roommate with pneumonia is an infection risk.Checked against:Low white blood cell count and cancer · MedlinePlus (NIH) (2025)
Answer
A · Strict hand hygiene, temperature checks and no visitors with infections
10.Lab values & electrolytes
Answer: D · Vitamin B12 deficiency
Why this is the answer
Long-term metformin reduces vitamin B12 absorption in the gut. B12 deficiency causes macrocytic anemia and peripheral neuropathy, which can be mistaken for diabetic neuropathy. Periodic B12 testing is recommended for long-term users.Checked against:Vitamin B Test · MedlinePlus (NIH) (2026)
Answer
D · Vitamin B12 deficiency
11.Pharmacology
Answer: A · To reduce the risk of oral thrush (candidiasis) and hoarseness
Why this is the answer
Steroid left in the mouth and throat suppresses local immunity and can cause candidiasis and a hoarse voice. Rinsing and spitting, and using a spacer, reduce this risk.
Answer
A · To reduce the risk of oral thrush (candidiasis) and hoarseness
12.Pharmacology
Answer: B · Respiratory alkalosis followed by metabolic acidosis
Why this is the answer
Salicylates stimulate breathing, causing respiratory alkalosis early. They then disturb cell metabolism, causing a metabolic acidosis with a raised anion gap. Adults often show a mixed picture.
Answer
B · Respiratory alkalosis followed by metabolic acidosis
13.Med-surg: cardiovascular & respiratory
Answer: A · Patient reclined at 45° with the head turned slightly to the left
Why this is the answer
With the patient at 45°, the vertical height of the pulsation in the right internal jugular vein above the sternal angle is estimated. A height above about 3–4 cm suggests raised right-sided pressure, as in right heart failure or fluid overload.
Answer
A · Patient reclined at 45° with the head turned slightly to the left
14.Med-surg: cardiovascular & respiratory
Answer: D · Nurse them in separate single rooms and keep them apart
Why this is the answer
People with CF are colonised with organisms such as Pseudomonas aeruginosa and Burkholderia cepacia complex that can pass between patients and worsen outcomes. They are cared for in single rooms and kept apart, without sharing equipment or sessions.
Answer
D · Nurse them in separate single rooms and keep them apart
15.Med-surg: neuro, endocrine & renal
Answer: C · In type 1 diabetes it is continued even when the patient is not eating
Why this is the answer
Basal insulin covers background needs and has a flat profile. In type 1 diabetes it must continue during illness or fasting (the dose may be adjusted) to prevent DKA. Glargine must not be mixed with other insulins.
Answer
C · In type 1 diabetes it is continued even when the patient is not eating
16.Med-surg: neuro, endocrine & renal
Answer: B · Hypoactive delirium
Why this is the answer
Hypoactive delirium presents with drowsiness, withdrawal and slowness rather than agitation, so it is often missed. It has a worse prognosis than the hyperactive form. A family report of a sudden change is important, and a screening tool such as the 4AT or the CAM (Confusion Assessment Method) can be used.
Answer
B · Hypoactive delirium
17.Med-surg: GI, perioperative & oncology
Answer: C · Intrinsic factor from the stomach is no longer made
Why this is the answer
Parietal cells of the stomach make intrinsic factor, which is needed for B12 absorption in the terminal ileum. Without it, pernicious-type anaemia and neuropathy develop unless B12 is given by injection.
Answer
C · Intrinsic factor from the stomach is no longer made
18.Med-surg: GI, perioperative & oncology
Answer: C · A patient with cirrhosis who is newly confused and drowsy
Why this is the answer
New confusion and drowsiness in cirrhosis may be hepatic encephalopathy with a precipitant such as bleeding or infection, and the airway may be at risk. The others are stable.
Answer
C · A patient with cirrhosis who is newly confused and drowsy
19.Maternity & obstetric nursing
Answer: A · It can close the fetal ductus arteriosus too early
Why this is the answer
Indomethacin inhibits prostaglandin synthesis. In the fetus this can cause premature closure of the ductus arteriosus and reduced fetal urine output with oligohydramnios, risks that increase with gestational age.
Answer
A · It can close the fetal ductus arteriosus too early
20.Maternity & obstetric nursing
Answer: B · Intravenous iron
Why this is the answer
When oral iron is not tolerated or not effective, intravenous iron may be used in the second and third trimesters. Transfusion is reserved for severe or symptomatic anaemia or acute blood loss.
Answer
B · Intravenous iron
21.Pediatric nursing
Answer: D · Respiratory rate and level of sedation
Why this is the answer
Opioids can cause respiratory depression, usually preceded by increasing sedation. Respiratory rate, sedation score, oxygen saturation and pain are monitored regularly, and naloxone is kept available.
Answer
D · Respiratory rate and level of sedation
22.Pediatric nursing
Answer: D · "I stop taking my preventer inhaler whenever I've had a few good days."
Why this is the answer
Preventer (inhaled corticosteroid) inhalers reduce airway inflammation and must be taken daily as prescribed, even when the child feels well. Carrying a reliever, rinsing the mouth and using a spacer are correct.
Answer
D · "I stop taking my preventer inhaler whenever I've had a few good days."
23.Mental health nursing
Answer: A · Codependency
Why this is the answer
Codependency describes a family member whose life becomes centred on the other person's addiction, often with caretaking, covering up and neglect of self. Support groups such as Al-Anon can help.
Answer
A · Codependency
24.Mental health nursing
Answer: D · Support a gradual, planned return to school with a consistent goodbye routine
Why this is the answer
Long-term avoidance strengthens anxiety. A gradual, planned return, short and predictable goodbyes, praise for brave behaviour and cooperation between parents and school, often with CBT, help the child cope.
Answer
D · Support a gradual, planned return to school with a consistent goodbye routine
25.Nursing math & unit conversions
Answer: h = 67.3 in
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Centimetres to inches
h = 171/2.54 = 67.32 ≈ 67.3 in
Answer
h = 67.3 in
26.Nursing math & unit conversions
Answer: c = 265 mg/dL
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
c = 14.7·18 = 264.6 ≈ 265 mg/dL
Answer
c = 265 mg/dL
27.Dosage calculations
Answer: V = 0.3 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.
Concentration
1:1000 = 1 g/1000 mL = 1 mg/mL
Volume
V = 0.3/1 = 0.3 mL
Answer
V = 0.3 mL
US labels now state mg/mL (1 mg/mL = 1:1000; 0.1 mg/mL = 1:10 000). Never give 1 mg/mL epinephrine IV push.
28.Dosage calculations
Answer: D = 99.28 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).
Body surface area
BSA = √(154·64/3600) = √2.738 = 1.655 m²
Dose
D = 60·1.655 = 99.28 mg
Answer
D = 99.28 mg
29.IV infusion rates
Answer: R = 56 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
3·60 = 180 min
Drip rate
R = 500·20/180 = 55.56 ≈ 56 gtt/min
Answer
R = 56 gtt/min
At the bedside you round to the nearest whole drop: 56 gtt/min.
30.IV infusion rates
Answer: D = 50 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
250/50 = 5 mg/mL
Dose rate
D = 5·10 = 50 mg/h
Answer
D = 50 mg/h
31.Pediatric & critical-care dosing
Answer: V = 4.9 mL
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 needed
60·82 = 4 920 units
Volume
V = 4920/1000 = 4.92 ≈ 4.9 mL
Answer
V = 4.9 mL
32.Pediatric & critical-care dosing
Answer: R = 16.5 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
250 mg = 250 000 mcg
250 000/250 = 1000 mcg/mL
Dose per minute and per hour
5·55 = 275 mcg/min
275·60 = 16500 mcg/h
Pump rate
R = 16500/1000 = 16.5 mL/h
Answer
R = 16.5 mL/h
33.IV fluids & fluid balance
Answer: B = 450 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total intake
oral: 300 + 100 = 400 mL
ice chips: 120/2 = 60 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1660 mL
Total output
250 + 500 + 400 + 60 = 1210 mL
Balance
B = 1660 − 1210 = 450 mL
Answer
B = 450 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 350 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
11:15 → 13:45 = 2.5 h
Volume infused
60·2.5 = 150 mL
Volume left
V = 500 − 150 = 350 mL
Answer
V = 350 mL
35.Clinical assessment scores
Answer: M = 3
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Motor score
M = 9 − 2 − 4 = 3
M3: abnormal flexion of the arms (decorticate posture)
Answer
M = 3
36.Clinical assessment scores
Answer: overweight
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 = 69/1.55² = 28.72
Category
overweight
Answer
overweight
37.Arterial blood gas interpretation
Answer: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.59: alkalaemia (above 7.45)
PaCO₂ 26 mmHg: low (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: AGc = 18.5 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 = 136 − (105 + 18) = 13
Correction for albumin
13 + 0.25·(40 − 18) = 18.5 mmol/L
Answer
AGc = 18.5 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: sinus rhythm with sinus arrest
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: 6 QRS complexes in 6 s, × 10 = 60 per minute.
2. Rhythm: regular (R–R 0.88 s) except for one pause of 1.40 s, which is not a whole number of P–P cycles.
3. P waves: upright, one before every QRS; no P wave at all during the pause.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
sinus rhythm with sinus arrest
Answer
sinus rhythm with sinus arrest
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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