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
Why do nurses often count the respiratory rate while still appearing to take the pulse?
AThe pulse and breathing rates are always the same number
BPatients who know their breathing is watched tend to change it
CIt is not allowed to tell patients that breathing is measured
DCounting breaths is only accurate when the wrist is held
2.Nursing fundamentalsHard
A dehydrated patient is receiving IV fluids. Which finding best shows the treatment is working?
AThe urine becomes darker and more concentrated
BUrine output rises and the heart rate falls towards normal
CThe heart rate rises and the skin becomes cooler
DThe patient feels more thirsty than before the fluids started
3.Infection control & patient safetyMedium
A patient is on seizure precautions. Which equipment should be ready at the bedside?
AWorking suction and oxygen equipment
BRestraints ready for all four limbs
CAn ice pack to place on the forehead
DA tongue blade to put between the teeth
4.Infection control & patient safetyHard
A patient with depression has suddenly become calm and is giving away personal possessions. What does this suggest?
AThat the patient is now ready for discharge today
BA possibly increased suicide risk that needs immediate assessment
CThat the patient wants to make new friends on the unit
DThat the depression has resolved and observation can be reduced
5.Prioritization & delegationMedium
A nurse teaches a patient to use an incentive spirometer. Which statement shows a need for further teaching?
A“I will use it several times every hour while awake.”
B“I will breathe in slowly and deeply through the mouthpiece.”
C“I will blow into it as hard and fast as I can.”
D“I will try to hold my breath for a few seconds at the top.”
6.Prioritization & delegationHard
Four patients arrive at the emergency department at the same time. Who should be seen first?
AA young adult with a swollen, painful ankle after a fall on the stairs
BAn adult with kidney stone pain of 9/10 and stable vital signs
CA child with a temperature of 39 °C who is alert and drinking
DAn older adult with weakness on one side that began 40 minutes ago
7.Clinical nursingMedium
Which advice should be given to a patient with a new permanent pacemaker?
AAvoid using all household electrical appliances such as kettles
BStop all heart medicines straight away
CNever raise the arm on that side again
DTell staff about the pacemaker before any MRI scan or procedure
8.Clinical nursingHard
A patient with long-standing COPD has an arterial blood gas with pH 7.37, a raised PaCO2 and a raised bicarbonate. How is this best described?
AUncompensated metabolic alkalosis
BAcute respiratory acidosis
CCompensated respiratory acidosis
DMixed metabolic and respiratory alkalosis
9.Lab values & electrolytesMedium
A patient had a total gastrectomy. Which long-term therapy is needed to prevent anemia?
ALifelong vitamin B12 replacement
BLifelong oral folic acid tablets only
CMonthly transfusions of red blood cells
DWeekly doses of oral vitamin K tablets
10.Lab values & electrolytesHard
Which cerebrospinal fluid (CSF) pattern most strongly suggests bacterial meningitis?
AClear fluid, normal glucose, mildly raised protein, lymphocytes
BClear fluid, high glucose, low protein, many red cells
CClear fluid, normal glucose, normal protein, no white cells
DCloudy fluid, low glucose, high protein, many neutrophils
11.PharmacologyMedium
Which adverse effect of ciprofloxacin should a patient report at once?
AA slightly bitter or metallic taste for a while after each dose
BDarker stools than usual
CPain or swelling in a tendon, such as the Achilles tendon
DMild tiredness in the first few days
12.PharmacologyHard
A patient taking a GLP-1 receptor agonist such as semaglutide has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?
AExpected nausea; the patient should take the next dose with food
BAcute pancreatitis; the drug is stopped and urgent assessment arranged
CHypoglycaemia; the patient should eat sweets and continue as usual
DConstipation; a laxative will solve the problem
13.Med-surg: cardiovascular & respiratoryMedium
A patient has central chest pain and a STEMI on the ECG. What does this usually require?
AAdmission and a repeat ECG the next morning
BEmergency reperfusion, preferably by primary PCI
CA troponin result before any treatment decision is made
DOral beta-blocker and discharge if pain settles
14.Med-surg: cardiovascular & respiratoryHard
A patient with a tracheostomy suddenly becomes distressed, and a suction catheter will not pass down the tube. What should the nurse do first?
AInflate the cuff with more air
BIncrease the oxygen and wait
CGive a nebulised bronchodilator
DRemove the inner cannula
15.Med-surg: neuro, endocrine & renalMedium
A patient has just started haemodialysis. What usually happens to their protein needs?
AThey stay exactly the same as they were before dialysis
BThey increase, because dialysis removes amino acids
CThey fall to almost zero to rest the kidneys
DProtein must be replaced only by IV infusion
16.Med-surg: neuro, endocrine & renalHard
Two days after an ileal conduit was formed, the stoma is dark purple and dry. What should the nurse do?
AReport it urgently, because the stoma may be ischaemic
BApply a warm compress to improve the colour of the stoma
CChange the bag and check again next week
DRecord it as normal for a new stoma
17.Med-surg: GI, perioperative & oncologyMedium
Which area is used as a quick estimate of 1% of body surface area for small or scattered burns?
AThe patient's palm including the fingers
BThe patient's thumbnail
CThe patient's hand and forearm
DThe examiner's palm including the fingers
18.Med-surg: GI, perioperative & oncologyHard
A patient who takes NSAIDs suddenly develops severe epigastric pain, a rigid abdomen and shoulder-tip pain. Which finding would most support the likely diagnosis?
ATall, peaked T waves on a 12-lead ECG
BFree air under the diaphragm on an erect chest X-ray
CA raised serum lipase three times the upper limit
DFluid levels in the bladder on an ultrasound scan
19.Maternity & obstetric nursingMedium
On day 2, a newborn has red blotches with small yellow-white centres on the trunk. The baby is well. What is most likely?
AHerpes simplex infection
BErythema toxicum
CNeonatal sepsis
DPort-wine stain
20.Maternity & obstetric nursingHard
A woman with gestational diabetes was on insulin during pregnancy. What change in her insulin needs is expected right after birth?
AShe will need lifelong insulin
BThey double because of the stress of birth, so the insulin dose is increased
CThey fall quickly, so glucose is monitored and insulin is often stopped
DThey stay the same for 6 weeks
21.Pediatric nursingMedium
How should a 3-year-old use a metered-dose inhaler?
AWith a spacer, giving all the prescribed puffs into it at the same time
BWith a spacer and mask, holding the breath for 10 seconds after each puff
CDirectly into the mouth without a spacer, while breathing in as fast as possible
DWith a spacer and face mask, taking several normal breaths after each puff
22.Pediatric nursingHard
After hypospadias repair, a toddler has a urinary catheter. Which nursing action has priority?
ARemove the dressing on the first day to check the wound
BClamp the catheter for a few hours to train the bladder
CKeep the catheter draining freely and check for kinks or blockage
DLimit fluids for the first days so that less urine passes over the repair
23.Mental health nursingMedium
A 24-year-old woman with bipolar disorder is starting valproate. What is the most important teaching point?
AIt is safe in pregnancy and needs no special precautions
BIt can seriously harm an unborn baby, so effective contraception and specialist advice are essential
CIt must be taken with grapefruit juice to be absorbed
DIt will cause her to lose weight quickly, so she should eat extra meals and snacks every day
24.Mental health nursingHard
A patient with bulimia nervosa has a serum potassium of 2.8 mmol/L. What is the main concern?
AA risk of weight gain
BIncreased appetite
CImproved muscle strength
DA risk of life-threatening cardiac arrhythmias
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 10:15 PM. Which entry is the same time on the 24-hour clock? Click it.
10:15 PM
121:15
223:15
310:15
422:15
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 2 tsp of an oral suspension every 6 hours for 10 days. Using 1 tsp = 5 mL, how many mL V are needed for the whole course?
2 tspevery 6 hours10 days1 tsp = 5 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 90 kg. The prescribed dose is 20 mg/kg per day, given in 4 equal doses. How many milligrams D are given per dose?
90 kg20 mg/kg/day4× per day
D = mg
28.Dosage calculationsHard
The prescription is 500 units of a drug that comes as 5000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
500 units5000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 6 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1500 mL6 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 2 g of a drug in 500 mL. The order is 2 mg per minute. At what rate R do you set the pump, in mL/h?
2 g/500 mL2 mg/min
R = mL/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 80 units/kg for a patient who weighs 99 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg99 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 56 kg has an order for nitroglycerin at 30 mcg/min. The bag contains 25 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
25 mg/250 mL30 mcg/min56 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 46 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 1000 mL infusion starts at 11:00 at 80 mL/h. After 4 hours the rate is changed to 125 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL80 mL/h · 4 h125 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 12/min, SpO₂ 99% on supplemental oxygen, blood pressure 142/86 mmHg, pulse 70/min, responds only to voice, temperature 36.4 °C. What is the NEWS2 total score?
RR 12SpO₂ 99%O₂SBP 142HR 70VT 36.4 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 25/min, SpO₂ 88% on supplemental oxygen, blood pressure 96/58 mmHg, pulse 70/min, alert, temperature 38.0 °C. Which clinical risk group does the patient fall into? Click it.
RR 25SpO₂ 88%O₂SBP 96HR 70AT 38.0 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 74 mmHg (9.9 kPa). Use the rule that in chronic respiratory acidosis HCO₃⁻ rises by 3.5 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
Practice values: Na⁺ 146, Cl⁻ 117 and HCO₃⁻ 12 mmol/L. Calculate the delta ratio (AG − 12)/(24 − HCO₃⁻), using AG = Na⁺ − (Cl⁻ + HCO₃⁻). Give two decimals.
Na⁺ 146 mmol/LCl⁻ 117 mmol/LHCO₃⁻ 12 mmol/L
delta ratio =
39.ECG rhythm strip interpretationMedium
This lead II strip shows atrial flutter with a fixed conduction ratio. Find the ventricular rate in beats per minute.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ventricular rate = bpm
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 fibrillation
2sinus bradycardia
3asystole
4junctional rhythm
3Solutions
1.Nursing fundamentals
Answer: B · Patients who know their breathing is watched tend to change it
Why this is the answer
Breathing can be changed on purpose, so a patient who is aware of being watched may breathe differently. Counting unobtrusively for a full minute gives a more accurate rate.
Answer
B · Patients who know their breathing is watched tend to change it
2.Nursing fundamentals
Answer: B · Urine output rises and the heart rate falls towards normal
Why this is the answer
With effective fluid replacement, perfusion improves: urine output increases, the heart rate settles and the blood pressure stabilises. Watching for fluid overload is also important.
Answer
B · Urine output rises and the heart rate falls towards normal
3.Infection control & patient safety
Answer: A · Working suction and oxygen equipment
Why this is the answer
Suction and oxygen are kept ready to manage secretions and support breathing during or after a seizure. Nothing is put in the mouth, and restraints are not used because they can cause injury.
Answer
A · Working suction and oxygen equipment
4.Infection control & patient safety
Answer: B · A possibly increased suicide risk that needs immediate assessment
Why this is the answer
A sudden improvement in mood with giving away belongings can mean the person has made a plan. The nurse assesses suicide risk directly, increases observation and informs the team.
Answer
B · A possibly increased suicide risk that needs immediate assessment
5.Prioritization & delegation
Answer: C · “I will blow into it as hard and fast as I can.”
Why this is the answer
An incentive spirometer is used by breathing in slowly and deeply, then holding the breath briefly. Blowing into it does not expand the lungs.
Answer
C · “I will blow into it as hard and fast as I can.”
6.Prioritization & delegation
Answer: D · An older adult with weakness on one side that began 40 minutes ago
Why this is the answer
Sudden one-sided weakness suggests a stroke, and treatment depends on how quickly it starts. Severe kidney stone pain needs prompt pain relief, but the patient is stable.
Answer
D · An older adult with weakness on one side that began 40 minutes ago
7.Clinical nursing
Answer: D · Tell staff about the pacemaker before any MRI scan or procedure
Why this is the answer
Patients carry a device card and tell staff before MRI, surgery with diathermy or similar procedures. Arm movement on the pacemaker side is limited only for a short period after insertion.
Answer
D · Tell staff about the pacemaker before any MRI scan or procedure
8.Clinical nursing
Answer: C · Compensated respiratory acidosis
Why this is the answer
Chronic CO2 retention is offset by the kidneys retaining bicarbonate, bringing the pH back to normal. A normal pH with high PaCO2 and high bicarbonate is a compensated respiratory acidosis.
Answer
C · Compensated respiratory acidosis
9.Lab values & electrolytes
Answer: A · Lifelong vitamin B12 replacement
Why this is the answer
Intrinsic factor from the stomach is needed to absorb vitamin B12 in the ileum. After a total gastrectomy, B12 must be replaced for life, usually by injection, to prevent macrocytic anemia and nerve damage.Checked against:Vitamin B12 or folate deficiency anaemia - Causes · NHS (2023); Vitamin B12 deficiency anemia · MedlinePlus (NIH) (2026)
Answer
A · Lifelong vitamin B12 replacement
10.Lab values & electrolytes
Answer: D · Cloudy fluid, low glucose, high protein, many neutrophils
Why this is the answer
Bacterial meningitis typically gives cloudy CSF with many neutrophils, high protein and low glucose, because bacteria and white cells use glucose. Viral meningitis usually shows lymphocytes with a normal glucose; option C is normal CSF.Checked against:CSF glucose test · MedlinePlus (NIH) (2025); CSF cell count · MedlinePlus (NIH) (2025); CSF total protein · MedlinePlus (NIH) (2025)
Answer
D · Cloudy fluid, low glucose, high protein, many neutrophils
11.Pharmacology
Answer: C · Pain or swelling in a tendon, such as the Achilles tendon
Why this is the answer
Fluoroquinolones can cause tendinitis and tendon rupture. Patients should stop exercise and report tendon pain promptly.
Answer
C · Pain or swelling in a tendon, such as the Achilles tendon
12.Pharmacology
Answer: B · Acute pancreatitis; the drug is stopped and urgent assessment arranged
Why this is the answer
Mild nausea is common with GLP-1 agonists, but severe persistent abdominal pain radiating to the back suggests pancreatitis. The drug is stopped and the patient needs urgent assessment, including serum lipase or amylase.
Answer
B · Acute pancreatitis; the drug is stopped and urgent assessment arranged
13.Med-surg: cardiovascular & respiratory
Answer: B · Emergency reperfusion, preferably by primary PCI
Why this is the answer
A STEMI usually reflects total occlusion of a coronary artery. Emergency reperfusion, preferably primary PCI (or thrombolysis if PCI cannot be done in time), is needed as soon as possible; "time is muscle". The decision is made on the ECG and symptoms, not on the troponin result.
Answer
B · Emergency reperfusion, preferably by primary PCI
14.Med-surg: cardiovascular & respiratory
Answer: D · Remove the inner cannula
Why this is the answer
Tracheostomy emergency guidance is to remove the inner cannula first, because it may be blocked with secretions. If the patient does not improve, the cuff is deflated and the tube may need to be removed. Oxygen is applied to the face and the stoma, and emergency help is called.
Answer
D · Remove the inner cannula
15.Med-surg: neuro, endocrine & renal
Answer: B · They increase, because dialysis removes amino acids
Why this is the answer
Before dialysis, a moderate protein intake may be advised. Dialysis removes amino acids and protein, so needs rise, and malnutrition is a common risk. A renal dietitian sets individual targets.
Answer
B · They increase, because dialysis removes amino acids
16.Med-surg: neuro, endocrine & renal
Answer: A · Report it urgently, because the stoma may be ischaemic
Why this is the answer
A dusky, purple or black stoma suggests poor blood supply and possible necrosis. It needs urgent surgical review. A healthy stoma is moist and pink to red, and some swelling is normal at first.
Answer
A · Report it urgently, because the stoma may be ischaemic
17.Med-surg: GI, perioperative & oncology
Answer: A · The patient's palm including the fingers
Why this is the answer
The patient's palm with the fingers together is about 1% of their total body surface area. It is useful for small or patchy burns. Simple erythema (superficial burns) is not included in the total.
Answer
A · The patient's palm including the fingers
18.Med-surg: GI, perioperative & oncology
Answer: B · Free air under the diaphragm on an erect chest X-ray
Why this is the answer
A perforated peptic ulcer releases air into the peritoneal cavity, seen under the diaphragm on an erect chest X-ray or on CT. Shoulder-tip pain is referred from diaphragmatic irritation. The patient is kept nil by mouth, resuscitated and referred urgently to surgeons.
Answer
B · Free air under the diaphragm on an erect chest X-ray
19.Maternity & obstetric nursing
Answer: B · Erythema toxicum
Why this is the answer
Erythema toxicum is a common, benign rash that appears in the first days and resolves without treatment. A well baby with a typical rash needs only reassurance, but blistering or an unwell baby needs review.
Answer
B · Erythema toxicum
20.Maternity & obstetric nursing
Answer: C · They fall quickly, so glucose is monitored and insulin is often stopped
Why this is the answer
The placenta produced the hormones that caused insulin resistance. After birth, glucose usually returns to normal, so insulin is often stopped and glucose is checked. She needs a glucose test some weeks after birth and long-term screening for type 2 diabetes.
Answer
C · They fall quickly, so glucose is monitored and insulin is often stopped
21.Pediatric nursing
Answer: D · With a spacer and face mask, taking several normal breaths after each puff
Why this is the answer
Young children need a spacer with a well-fitting face mask. One puff is given at a time, and the child breathes normally for several breaths (often 5–10) to inhale the medicine. Several puffs at once reduce the dose delivered.
Answer
D · With a spacer and face mask, taking several normal breaths after each puff
22.Pediatric nursing
Answer: C · Keep the catheter draining freely and check for kinks or blockage
Why this is the answer
After repair, the catheter or stent protects the new urethra while it heals. It must drain freely; blockage causes bladder spasm and pressure on the repair. Fluids are encouraged, and the dressing is managed as the surgeon directs.
Answer
C · Keep the catheter draining freely and check for kinks or blockage
23.Mental health nursing
Answer: B · It can seriously harm an unborn baby, so effective contraception and specialist advice are essential
Why this is the answer
Valproate is highly teratogenic, causing neural tube defects and developmental problems. Women who could become pregnant need clear information, effective contraception and specialist review.
Answer
B · It can seriously harm an unborn baby, so effective contraception and specialist advice are essential
24.Mental health nursing
Answer: D · A risk of life-threatening cardiac arrhythmias
Why this is the answer
Repeated vomiting causes hypokalaemia and metabolic alkalosis. A potassium of 2.8 mmol/L is dangerously low and can cause arrhythmias. The patient needs cardiac monitoring and potassium replacement as prescribed.
Answer
D · A risk of life-threatening cardiac arrhythmias
25.Nursing math & unit conversions
Answer: 22:15
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
10 PM → 10 + 12 = 22
Answer
22:15
Answer
22:15
26.Nursing math & unit conversions
Answer: V = 400 mL
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.
Volume per dose
2 tsp = 2·5 = 10 mL
Whole course
V = 10 mL × 4/day × 10 = 400 mL
Answer
V = 400 mL
27.Dosage calculations
Answer: D = 450 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
20·90 = 1800 mg
Per dose
D = 1800/4 = 450 mg
Answer
D = 450 mg
28.Dosage calculations
Answer: V = 0.1 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 500/5000 = 0.1 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.1 mL
29.IV infusion rates
Answer: R = 83 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
6·60 = 360 min
Drip rate
R = 1500·20/360 = 83.33 ≈ 83 gtt/min
Answer
R = 83 gtt/min
At the bedside you round to the nearest whole drop: 83 gtt/min.
30.IV infusion rates
Answer: R = 30 mL/h
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
2000 mg/500 mL = 4 mg/mL
Dose per hour
2·60 = 120 mg/h
Pump rate
R = 120/4 = 30 mL/h
Answer
R = 30 mL/h
31.Pediatric & critical-care dosing
Answer: V = 7.9 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
80·99 = 7 920 units
Volume
V = 7920/1000 = 7.92 ≈ 7.9 mL
Answer
V = 7.9 mL
32.Pediatric & critical-care dosing
Answer: R = 18 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
25 000/250 = 100 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
30·60 = 1800 mcg/h
Pump rate
R = 1800/100 = 18 mL/h
Answer
R = 18 mL/h
33.IV fluids & fluid balance
Answer: U = 2.51 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
425 + 500 = 925 mL
Per kilogram per hour
U = 925/(46·8) = 2.514 ≈ 2.51 mL/kg/h
Answer
U = 2.51 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 9.4 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.
First part
80·4 = 320 mL
1000 − 320 = 680 mL left
Second part
680/125 = 5.44 h
Total time
t = 4 + 5.44 = 9.44 ≈ 9.4 h
Answer
t = 9.4 h
That is about 9 h 26 min, so the bag runs out at about 20:26.
35.Clinical assessment scores
Answer: NEWS2 = 5
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 12/min → 0
SpO₂ 99% → 0
on oxygen → 2
SBP 142 mmHg → 0
HR 70/min → 0
responds only to voice (V) → 3
T 36.4 °C → 0
Add
NEWS2 = 0 + 0 + 2 + 0 + 0 + 3 + 0 = 5
Answer
NEWS2 = 5
36.Clinical assessment scores
Answer: high
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 25/min → 3
SpO₂ 88% → 3
on oxygen → 2
SBP 96 mmHg → 2
HR 70/min → 0
alert (A) → 0
T 38.0 °C → 0
Total and red scores
NEWS2 = 3 + 3 + 2 + 2 + 0 + 0 + 0 = 10
At least one parameter scores 3.
Risk group
high
Answer
high
A total of 5 or more calls for an urgent clinical response.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 35.9 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.
Change in PaCO₂
|74 − 40| = 34 mmHg → 3.4 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·3.4 = 35.9 mmol/L
Answer
HCO₃⁻ = 35.9 mmol/L
38.Arterial blood gas interpretation
Answer: delta ratio = 0.4167
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 − (117 + 12) = 17
Delta ratio
(17 − 12)/(24 − 12) = 5/12 = 0.4167
Answer
delta ratio = 0.4167
Below 1: an added normal anion gap acidosis.
39.ECG rhythm strip interpretation
Answer: ventricular rate = 150 bpm
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.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 10 small boxes = 0.40 s → 1500 ÷ 10 = 150 per minute
conduction ratio = 300 ÷ 150 = 2:1
Answer
ventricular rate = 150 bpm
40.ECG rhythm strip interpretation
Answer: asystole
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: no countable ventricular rate.
2. Rhythm: none; an almost flat line.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: no QRS complexes.
Interpretation
asystole
Answer
asystole
A flat line is always checked: look at the patient, the leads and the gain, and view a second lead, because a loose electrode or fine VF can look like asystole.
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