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
When should hands be washed with soap and water instead of alcohol hand rub?
AOnly at the start of the shift
BBefore every routine observation
CWhen the hands are visibly dirty or soiled
DNever, because alcohol rub is always better
2.Nursing fundamentalsHard
A Waterlow or Braden score is used to assess:
AFall risk
BNutritional status only
CLevel of consciousness
DPressure ulcer risk
3.Infection control & patient safetyMedium
Which part of a sterile surgical gown is considered sterile once it is on?
AThe front from the neck down to the knees
BThe whole gown, including the back, the collar and the area below the waist
COnly the back of the gown, which nobody touches
DThe front from chest to the level of the sterile field, and the sleeves
4.Infection control & patient safetyHard
A patient refuses to wear an identification wristband. What should the nurse do?
AForce the band onto the patient’s wrist
BAccept the refusal and identify the patient by room number and bed space instead
CExplain why it is needed, use other ID methods per policy and document
DStop giving the patient any care until they agree to wear the band
5.Prioritization & delegationMedium
A patient with asthma has two inhalers: a corticosteroid and salbutamol (albuterol). Which statement shows a need for further teaching?
A“I will carry my salbutamol inhaler with me.”
B“I will rinse my mouth after using the steroid inhaler.”
C“I will use my steroid inhaler every day, even when I feel well.”
D“I will use my steroid inhaler when I have a sudden attack.”
6.Prioritization & delegationHard
A patient with diabetes is sweaty and confused, and no glucose meter is available. The patient can swallow. What should the nurse do?
AGive a dose of rapid-acting insulin in case the glucose is high
BTreat for hypoglycemia with fast-acting oral carbohydrate
CWithhold all food and fluids until a meter is found
DAsk the patient to lie down and sleep it off
7.Clinical nursingMedium
Why are older adults at higher risk of dehydration?
AThey always drink large amounts of tea
BTheir body water content increases with age
CTheir sense of thirst is often reduced
DTheir kidneys hold on to too much water
8.Clinical nursingHard
A nurse notices that a wrong dose of a drug was prepared but was caught before it was given. What should be done?
ASay nothing, because no harm reached the patient
BDiscipline the nurse who prepared it on the spot in front of colleagues
CReport it as a near miss through the incident reporting system
DTell only the patient's family
9.Lab values & electrolytesMedium
A patient who is breathless during a transfusion has hypotension, fever and bilateral lung infiltrates, with no signs of fluid overload. Which complication is most likely?
AA simple allergic reaction with hives
BA mild febrile nonhemolytic reaction
CTransfusion-related acute lung injury (TRALI)
DTransfusion-associated circulatory overload
10.Lab values & electrolytesHard
A patient on stable digoxin starts amiodarone. A week later, the patient has nausea and visual changes, and the digoxin level is above the range. What is the most likely explanation?
AAmiodarone has lowered potassium only
BAmiodarone has raised the digoxin level
CThe patient has started a viral illness
DDigoxin has raised the amiodarone level
11.PharmacologyMedium
Which serious but rare adverse effect of statins should patients report straight away?
AA dry cough
BUnexplained muscle pain or weakness
CAnkle swelling
DA metallic taste
12.PharmacologyHard
An older woman started on an SSRI two weeks ago is now confused, and her plasma sodium is low. What is the most likely mechanism?
ALoss of sodium through severe diarrhoea caused by the SSRI
BDirect damage to the adrenal glands
CSSRI-induced inappropriate ADH secretion causing water retention
DIncreased aldosterone secretion
13.Med-surg: cardiovascular & respiratoryMedium
Why must anti-embolism stockings be measured and fitted correctly?
ATight stockings work better, so the smallest size is always best
BPoorly fitting stockings can cause pressure damage
CCorrect fit is needed only to improve the appearance
DLoose stockings make the patient's legs too warm at night
14.Med-surg: cardiovascular & respiratoryHard
A patient with heart failure is breathless at rest, with cool peripheries, a systolic BP of 80 mmHg and falling urine output. What does this suggest?
ACardiogenic shock with poor tissue perfusion
BAnxiety causing a vasovagal response
CStable, well-compensated chronic heart failure
DMild dehydration that oral fluids will correct
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 has a sharp peak in action about 30 minutes after injection
CIn type 1 diabetes it is continued even when the patient is not eating
DIt is mixed with rapid-acting insulin in the same syringe
16.Med-surg: neuro, endocrine & renalHard
A patient with type 1 diabetes is vomiting at home. Their glucose is 12 mmol/L (216 mg/dL), and blood ketones are 3.5 mmol/L. What advice is correct?
AStop insulin until the vomiting has settled
BDrink less fluid to stop the vomiting
CWait until the glucose is above 20 mmol/L (360 mg/dL)
DSeek urgent hospital assessment for possible DKA
17.Med-surg: GI, perioperative & oncologyMedium
Why do patients with major burns lose so much fluid in the first 24–48 hours?
AThe kidneys stop making urine completely
BLeaky capillaries let plasma move into the tissues
CThe burned skin absorbs fluid from the air
DPatients drink far too little in hospital in the first days
18.Med-surg: GI, perioperative & oncologyHard
After forearm fracture surgery, a patient has severe pain not eased by opioids, made worse by passively moving the fingers. What should the nurse do?
AReassure the patient that this pain is expected
BLoosen any tight dressing, keep the arm at heart level and escalate
CApply ice and a tighter bandage to reduce the swelling
DRaise the arm as high as possible and give a further dose of opioid
19.Maternity & obstetric nursingMedium
Which substance in amniotic fluid is used to judge fetal lung maturity?
AGlucose, assessed by its concentration
BSurfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
CAlpha-fetoprotein, assessed by its level
DBilirubin, assessed by its colour
20.Maternity & obstetric nursingHard
Which statement by a woman in early labour shows a need for further teaching about pain relief?
A"If I have an epidural, I will not need my blood pressure checked."
B"Breathing slowly and focusing can help between contractions."
C"A warm bath or shower may ease the pain."
D"Changing position often and walking can help me cope."
21.Pediatric nursingMedium
Which nursing precaution applies to a child with a suspected Wilms tumour (nephroblastoma)?
AEncourage vigorous abdominal massage
BAvoid palpating the abdomen
CGive daily enemas
DKeep the child flat in bed for 2 weeks
22.Pediatric nursingHard
Which complication is a leading cause of death from measles in children?
AOtitis media
BDiarrhoea
CConjunctivitis
DPneumonia
23.Mental health nursingMedium
A patient asks the nurse for her home phone number so they can keep in touch after discharge. What is the best response?
A"Of course, as long as you don't tell the other patients."
B"I'll give you my number, but please only call me at weekends when I'm not working, and keep it short."
C"That would be against the rules, so please stop asking about it."
D"I can't give you my number, because our relationship is a professional one. Let's talk about support you can contact after discharge."
24.Mental health nursingHard
In the second session of a new therapy group, members argue about rules and one member challenges the leader's authority. How should the leader interpret this?
AThe member who challenged the leader should be removed
BIt is a normal stage of group development, to be handled openly and calmly
CThe group has failed and should be ended before anyone is upset
DThe leader should avoid all conflict by making every decision alone
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 39.4 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
39.4 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 2 mg/h. Express this dose rate D in mcg/min. Round to one decimal place.
2 mg/h1 mg = 1000 mcg1 h = 60 min
D = mcg/min
27.Dosage calculationsMedium
A prefilled syringe of epinephrine (adrenaline) is labelled 1:10 000 (0.1 mg/mL). The prescription is 1 mg IV in cardiac arrest. What volume V do you give?
1:10 0001 mg
V = mL
28.Dosage calculationsHard
An infusion contains 20000 units of a drug in 500 mL. The prescription is 800 units per hour. At what rate R do you set the pump, in mL/h?
20000 units/500 mL800 units/h
R = mL/h
29.IV infusion ratesMedium
1500 mL was ordered over 6 hours. After 4 hours you find that 600 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
1500 mL / 6 hafter 4 h: 600 mL
R = mL/h
30.IV infusion ratesHard
A drip runs at 30 gtt/min through a set of 20 gtt/mL. There are 200 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
30 gtt/min20 gtt/mL200 mL
t = 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 76 kg. The vial contains 5 000 units/mL. What volume V do you draw up? Round to two decimal places.
60 units/kg76 kg5 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 400 mg in 250 mL. The order is 15 mcg/kg/min for a patient who weighs 68 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL15 mcg/kg/min68 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 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
tea: 240 mLjuice: 200 mLIV infusion: 80 mL/h × 12 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 12:45 and runs by pump at 60 mL/h. How many mL V are left in the bag at 13:45?
500 mL60 mL/h12:45 → 13:45
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 6, with E2 and V2. What motor score M was recorded, and which response does it describe? Give the number.
GCS 6E2V2
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 18/min, SpO₂ 98% on room air, blood pressure 118/70 mmHg, pulse 70/min, alert, temperature 37.5 °C. Which clinical risk group does the patient fall into? Click it.
RR 18SpO₂ 98%airSBP 118HR 70AT 37.5 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.12, PaCO₂ 19 mmHg (2.5 kPa) and HCO₃⁻ 6 mmol/L. The primary disorder is metabolic acidosis. How far is it compensated? Click your answer.
pH 7.12PaCO₂ 19 mmHg (2.5 kPa)HCO₃⁻ 6 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a respiratory acidosis: pH 7.18, PaCO₂ 78 mmHg (10.4 kPa), HCO₃⁻ 28 mmol/L. Use the rules ‘HCO₃⁻ rises 1 mmol/L per 10 mmHg (acute) or 3.5 mmol/L per 10 mmHg (chronic)’ to classify it. Click your answer.
pH 7.18PaCO₂ 78 mmHg (10.4 kPa)HCO₃⁻ 28 mmol/L
1acute
2chronic
3acute on chronic
39.ECG rhythm strip interpretationMedium
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Bazett’s formula QTc = QT/√RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the 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 paced rhythm
2dual-chamber (AV) paced rhythm
3paced rhythm, failure to capture
4sinus rhythm with wide QRS
3Solutions
1.Nursing fundamentals
Answer: C · When the hands are visibly dirty or soiled
Why this is the answer
Soap and water are needed when hands are visibly dirty or contaminated with body fluids. On visibly clean hands, alcohol rub is quick and effective for most of the five moments.
Answer
C · When the hands are visibly dirty or soiled
2.Nursing fundamentals
Answer: D · Pressure ulcer risk
Why this is the answer
Both scales estimate the risk of pressure injuries and guide prevention such as repositioning, pressure-relieving mattresses and nutrition support.
Answer
D · Pressure ulcer risk
3.Infection control & patient safety
Answer: D · The front from chest to the level of the sterile field, and the sleeves
Why this is the answer
Only the front of the gown from chest to the level of the sterile field and the sleeves from above the elbow to the cuffs are sterile. The back, the neckline and anything below the sterile field are non-sterile.
Answer
D · The front from chest to the level of the sterile field, and the sleeves
4.Infection control & patient safety
Answer: C · Explain why it is needed, use other ID methods per policy and document
Why this is the answer
The nurse explains how the band prevents errors. If the patient still refuses, the nurse follows policy for alternative identification using two identifiers, informs the team and documents it.
Answer
C · Explain why it is needed, use other ID methods per policy and document
5.Prioritization & delegation
Answer: D · “I will use my steroid inhaler when I have a sudden attack.”
Why this is the answer
Inhaled corticosteroids reduce inflammation over time and do not relieve an acute attack. Salbutamol (albuterol) is the quick-relief inhaler; rinsing after steroids helps prevent oral thrush.
Answer
D · “I will use my steroid inhaler when I have a sudden attack.”
6.Prioritization & delegation
Answer: B · Treat for hypoglycemia with fast-acting oral carbohydrate
Why this is the answer
When in doubt, treat as hypoglycemia. A little sugar will not harm a patient with high glucose, but untreated hypoglycemia can cause brain injury within minutes, and insulin could be fatal.
Answer
B · Treat for hypoglycemia with fast-acting oral carbohydrate
7.Clinical nursing
Answer: C · 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
C · Their sense of thirst is often reduced
8.Clinical nursing
Answer: C · Report it as a near miss through the incident reporting system
Why this is the answer
Near misses are reported so that causes can be studied and systems improved. A just, open culture encourages reporting without blame.
Answer
C · Report it as a near miss through the incident reporting system
9.Lab values & electrolytes
Answer: C · Transfusion-related acute lung injury (TRALI)
Why this is the answer
TRALI is acute lung injury within 6 hours of transfusion, caused by donor antibodies activating neutrophils in the lungs. It causes hypoxia, bilateral infiltrates and often hypotension and fever. TACO, in contrast, causes hypertension and signs of fluid overload.
Answer
C · Transfusion-related acute lung injury (TRALI)
10.Lab values & electrolytes
Answer: B · Amiodarone has raised the digoxin level
Why this is the answer
Amiodarone reduces digoxin clearance, so the level can rise significantly, and the digoxin dose is often reduced when amiodarone is started. Nausea and visual changes are classic signs of digoxin toxicity.
Answer
B · Amiodarone has raised the digoxin level
11.Pharmacology
Answer: B · Unexplained muscle pain or weakness
Why this is the answer
Statins can cause myopathy, which rarely progresses to rhabdomyolysis with kidney damage. Unexplained muscle pain should be checked, for example with a creatine kinase level.
Answer
B · Unexplained muscle pain or weakness
12.Pharmacology
Answer: C · SSRI-induced inappropriate ADH secretion causing water retention
Why this is the answer
SSRIs can cause the syndrome of inappropriate antidiuretic hormone secretion (SIADH), especially in older people. Water retention dilutes plasma sodium, causing hyponatraemia and confusion.
Answer
C · SSRI-induced inappropriate ADH secretion causing water retention
13.Med-surg: cardiovascular & respiratory
Answer: B · Poorly fitting stockings can cause pressure damage
Why this is the answer
Stockings that are the wrong size or that roll down can act like a tourniquet and cause skin and pressure damage. They are measured to the leg, checked daily, and avoided in significant peripheral arterial disease, severe neuropathy or leg skin damage.
Answer
B · Poorly fitting stockings can cause pressure damage
14.Med-surg: cardiovascular & respiratory
Answer: A · Cardiogenic shock with poor tissue perfusion
Why this is the answer
Cardiogenic shock is pump failure with hypotension and hypoperfusion (cool skin, oliguria, confusion, raised lactate), often with pulmonary congestion. It needs urgent critical care review. Large fluid boluses can worsen congestion unless guided by careful assessment.
Answer
A · Cardiogenic shock with poor tissue perfusion
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: D · Seek urgent hospital assessment for possible DKA
Why this is the answer
Blood ketones above 3 mmol/L, especially with vomiting, mean a high risk of DKA, even if the glucose is only moderately raised. The patient needs urgent assessment. Insulin should not be stopped.
Answer
D · Seek urgent hospital assessment for possible DKA
17.Med-surg: GI, perioperative & oncology
Answer: B · Leaky capillaries let plasma move into the tissues
Why this is the answer
Inflammatory mediators make capillaries leaky, so plasma moves into the tissues and from the burn surface. Without fluids this causes burn shock; oedema is greatest in the first day or two.
Answer
B · Leaky capillaries let plasma move into the tissues
18.Med-surg: GI, perioperative & oncology
Answer: B · Loosen any tight dressing, keep the arm at heart level and escalate
Why this is the answer
These are early signs of compartment syndrome, where raised pressure in a muscle compartment reduces blood flow. Constrictive dressings are released, the limb is kept at heart level and urgent surgical review is needed, as fasciotomy may be required.
Answer
B · Loosen any tight dressing, keep the arm at heart level and escalate
19.Maternity & obstetric nursing
Answer: B · Surfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
Why this is the answer
Surfactant reduces surface tension and keeps alveoli open. An L/S ratio of about 2:1 or more suggests the lungs are mature. Amniotic fluid testing for lung maturity is now rarely used in practice.
Answer
B · Surfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
20.Maternity & obstetric nursing
Answer: A · "If I have an epidural, I will not need my blood pressure checked."
Why this is the answer
Epidurals often cause hypotension, so blood pressure is checked frequently after they are started. Movement, breathing techniques and warm water are effective non-drug measures.
Answer
A · "If I have an epidural, I will not need my blood pressure checked."
21.Pediatric nursing
Answer: B · Avoid palpating the abdomen
Why this is the answer
Palpating the abdomen could rupture the tumour capsule and spread cancer cells. A sign over the bed often warns staff not to palpate.
Answer
B · Avoid palpating the abdomen
22.Pediatric nursing
Answer: D · Pneumonia
Why this is the answer
Pneumonia, from measles itself or from secondary bacterial infection, causes most measles-related deaths in children. Encephalitis is a rarer but serious complication; vaccination prevents both.
Answer
D · Pneumonia
23.Mental health nursing
Answer: D · "I can't give you my number, because our relationship is a professional one. Let's talk about support you can contact after discharge."
Why this is the answer
Personal contact outside the therapeutic relationship crosses a professional boundary. The nurse explains the boundary kindly and redirects to appropriate after-discharge support.
Answer
D · "I can't give you my number, because our relationship is a professional one. Let's talk about support you can contact after discharge."
24.Mental health nursing
Answer: B · It is a normal stage of group development, to be handled openly and calmly
Why this is the answer
Conflict and challenges to the leader are typical of the storming stage. Handling them openly and non-defensively helps the group develop norms and move into productive work.
Answer
B · It is a normal stage of group development, to be handled openly and calmly
25.Nursing math & unit conversions
Answer: T = 102.9 °F
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Multiply by 9/5
39.4·9/5 = 70.92
Add 32
T = 70.92 + 32 = 102.9 °F
Answer
T = 102.9 °F
26.Nursing math & unit conversions
Answer: D = 33.3 mcg/min
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Set up the chain
D = 2 mg/h × (1000 mcg/1 mg) × (1 h/60 min)
Calculate
D = 2000/60 = 33.33 ≈ 33.3 mcg/min
Answer
D = 33.3 mcg/min
27.Dosage calculations
Answer: V = 10 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
1:10 000 = 1 g/10000 mL = 0.1 mg/mL
Volume
V = 1/0.1 = 10 mL
Answer
V = 10 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: R = 20 mL/h
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.
Concentration
20000/500 = 40 units/mL
Pump rate
R = 800/40 = 20 mL/h
Answer
R = 20 mL/h
29.IV infusion rates
Answer: R = 300 mL/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.
Original rate
1500/6 = 250 mL/h
New rate
R = 600/2 = 300 mL/h
Answer
R = 300 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: t = 2.2 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
30·60/20 = 90 mL/h
Time left
t = 200/90 = 2.222 ≈ 2.2 h
Answer
t = 2.2 h
31.Pediatric & critical-care dosing
Answer: V = 0.91 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
60·76 = 4 560 units
Volume
V = 4560/5000 = 0.912 ≈ 0.91 mL
Answer
V = 0.91 mL
32.Pediatric & critical-care dosing
Answer: R = 38.3 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
400 mg = 400 000 mcg
400 000/250 = 1600 mcg/mL
Dose per minute and per hour
15·68 = 1020 mcg/min
1020·60 = 61200 mcg/h
Pump rate
R = 61200/1600 = 38.25 ≈ 38.3 mL/h
Answer
R = 38.3 mL/h
33.IV fluids & fluid balance
Answer: I = 1500 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: 240 + 200 = 440 mL
IV infusion: 80·12 = 960 mL
IV antibiotic: 1·100 = 100 mL
I = 1500 mL
Answer
I = 1500 mL
34.IV fluids & fluid balance
Answer: V = 440 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
12:45 → 13:45 = 1 h
Volume infused
60·1 = 60 mL
Volume left
V = 500 − 60 = 440 mL
Answer
V = 440 mL
35.Clinical assessment scores
Answer: M = 2
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 = 6 − 2 − 2 = 2
M2: extension of the arms and legs (abnormal extension)
Answer
M = 2
36.Clinical assessment scores
Answer: low
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 18/min → 0
SpO₂ 98% → 0
on air → 0
SBP 118 mmHg → 0
HR 70/min → 0
alert (A) → 0
T 37.5 °C → 0
Total and red scores
NEWS2 = 0 + 0 + 0 + 0 + 0 + 0 + 0 = 0
No parameter scores 3.
Risk group
low
Answer
low
37.Arterial blood gas interpretation
Answer: partially 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 7.12: acidaemia (below 7.35)
PaCO₂ 19 mmHg: low (35–45)
HCO₃⁻ 6 mmol/L: low (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: acute
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected HCO₃⁻
acute: 24 + 1·3.8 = 27.8 mmol/L
chronic: 24 + 3.5·3.8 = 37.3 mmol/L
Compare
measured: 28 mmol/L → acute
Answer
acute
39.ECG rhythm strip interpretation
Answer: QTc = 0.524 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 12 × 0.04 = 0.48 s
RR = 21 × 0.04 = 0.84 s
Bazett’s formula
QTc = 0.48/√0.84 = 0.48/0.9165 = 0.524 s
Answer
QTc = 0.524 s
Above 0.50 s: markedly prolonged. (524 ms)
40.ECG rhythm strip interpretation
Answer: ventricular paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 25 small boxes, 1500 ÷ 25 ≈ 60 per minute.
2. Rhythm: regular, every R–R is 1.00 s.
3. P waves: none visible; a sharp pacing spike comes just before every QRS.
4. PR interval: not measurable.
5. QRS: 0.14 s, wide, and every spike is followed by a QRS (capture).
Interpretation
ventricular paced rhythm
Answer
ventricular paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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