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
Before discharge, what is most important to confirm about the patient's new medicines?
AThat they know the chemical name of each drug
BThat they know how and when to take them and what to report
CThat they know the price of each medicine and where to buy it
DThat they know which company makes each drug
2.Nursing fundamentalsHard
Why must concentrated potassium chloride never be given as a quick intravenous injection?
AIt can cause a fatal cardiac arrest
BIt stops the kidneys from working at once
CIt makes the vein turn blue for a week
DIt makes the potassium inactive in the blood
3.Infection control & patient safetyMedium
A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?
AVisit only if the cold started more than a day ago
BVisit as usual after washing the hands
CVisit but avoid touching the patient’s bed
DPostpone the visit until the visitor is well
4.Infection control & patient safetyHard
Several patients on a ward develop vomiting and diarrhea within two days, and a norovirus outbreak is suspected. What should the nurse do first?
ANotify the infection prevention team and place affected patients on contact precautions
BMove the affected patients to different wards so that fewer people are exposed
CWait for all the stool results to come back before taking any action
DAsk visitors to bring in bottled water for all patients
5.Prioritization & delegationMedium
A patient asks the nursing assistant about the side effects of a new medication. What should the assistant do?
AReassure the patient that side effects are rare
BSay the nurse will come to answer, and tell the nurse
CLook the drug up online and read out what it says
DExplain the side effects listed in the drug’s patient leaflet
6.Prioritization & delegationHard
A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?
AA spiral fracture in an infant is always caused by birth trauma
BInfants of this age often roll off furniture and break bones in this way
CThe injury does not fit the infant’s development, so possible abuse must be reported
DNo further action is needed once the fracture is treated
7.Clinical nursingMedium
Which adverse effects should be monitored for in a patient receiving IV gentamicin?
AHair loss and weight gain
BHyperglycaemia and tremor
CConstipation and urinary retention
DKidney damage and hearing loss
8.Clinical nursingHard
A patient on an unfractionated heparin infusion is also started on warfarin. Which tests are used to monitor each drug?
AINR for heparin and APTT for warfarin
BPlatelet count for both drugs
CAPTT for heparin and INR for warfarin
DD-dimer for both drugs
9.Lab values & electrolytesMedium
A patient on peritoneal dialysis notices that the drained fluid is cloudy and has abdominal pain. What should the nurse do?
ASend the fluid for cell count and culture and report it
BRecord it as normal and continue the usual exchanges
CStop dialysis for a week and recheck the fluid later
DAdd more glucose to the next bag to clear the fluid
10.Lab values & electrolytesHard
A patient has a continuous heparin infusion for a pulmonary embolism. A new nurse plans to adjust the infusion using today's INR of 1.1. What should the experienced nurse explain?
AHeparin is adjusted using the aPTT or anti-Xa level, not the INR
BThe INR is the correct test, and 1.1 means heparin is therapeutic
CHeparin needs no laboratory monitoring once the infusion is started
DThe INR of 1.1 means the heparin rate must be doubled at once
11.PharmacologyMedium
A patient must mix regular (soluble) insulin and NPH (isophane) insulin in one syringe. What is the correct order?
AShake both vials hard, then draw them up in any order
BDraw them up in separate syringes, then mix them in a cup
CDraw up the cloudy NPH insulin first, then the clear regular insulin
DDraw up the clear regular insulin first, then the cloudy NPH insulin
12.PharmacologyHard
Why is sildenafil contraindicated in a patient who uses nitrates for angina?
ANitrates block the metabolism of sildenafil in the liver
BThe combination causes dangerous hyperkalaemia
CBoth raise cGMP in vascular smooth muscle and can cause severe hypotension
DSildenafil blocks the conversion of nitrates into nitric oxide in the vessels
13.Med-surg: cardiovascular & respiratoryMedium
Why is a shock for cardioversion synchronised with the QRS complex?
ATo avoid delivering the shock during the T wave
BTo allow the use of a lower battery charge
CTo make the shock less painful for the patient
DTo keep the pads from burning the skin
14.Med-surg: cardiovascular & respiratoryHard
On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?
ACall for expert help and give oxygen to both the face and the stoma
BCover the stoma completely with a sealed dressing and wait for help
CLeave the patient alone while fetching a new tube
DForce the tube back through the stoma immediately with firm pressure
15.Med-surg: neuro, endocrine & renalMedium
For which patient would the nurse question an order for pioglitazone?
AA patient with hypothyroidism
BA patient with heart failure
CA patient with an allergy to latex
DA patient with asthma
16.Med-surg: neuro, endocrine & renalHard
A patient taking lithium has polyuria and thirst, and the urine does not concentrate after desmopressin. What is the most likely cause?
ANephrogenic DI caused by lithium
BNewly developed type 1 diabetes
CCranial DI after a head injury
DSIADH caused by lithium
17.Med-surg: GI, perioperative & oncologyMedium
Which PPE is usually recommended when giving cytotoxic chemotherapy?
AA paper surgical mask but no gloves
BChemo-tested gloves and impermeable gown
COrdinary cotton gloves and a plastic apron
DNo PPE, because the infusion bag is sealed
18.Med-surg: GI, perioperative & oncologyHard
A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?
AEncourage the patient to rest the voice and reassess tomorrow
BGive a warm drink to soothe the throat
CLay the patient flat to help them sleep
DCall for urgent anaesthetic help, as the airway is swelling
19.Maternity & obstetric nursingMedium
How does breast milk jaundice usually differ from early breastfeeding jaundice?
AIt appears later, after the first week, in a thriving baby
BIt always needs the baby to stop breastfeeding permanently
CIt appears in the first 24 hours in a sick baby
DIt is caused by too little milk intake
20.Maternity & obstetric nursingHard
Fluid leaking from the vagina is tested. Which result supports rupture of the membranes?
AA ferning pattern on a dried slide under the microscope
BA nitrazine test that turns yellow, showing acidic fluid
CFluid that contains glucose on a urine dipstick
DFluid that smells of ammonia
21.Pediatric nursingMedium
A family has a 2-year-old. Which advice about medicines at home is best?
ACall medicines "sweets" so the child is happy to take them
BRely on child-resistant caps alone, since toddlers are not strong enough to open them
CLock all medicines away, out of reach and sight, in child-resistant containers
DKeep daily medicines in a handbag so they are always at hand
22.Pediatric nursingHard
Which finding in a child with a ventriculoperitoneal shunt requires immediate follow-up?
AHeadache, repeated vomiting and increasing drowsiness
BNormal appetite and play
CA small, soft bump over the valve that is unchanged
DA healed scar along the shunt tract
23.Mental health nursingMedium
Flumazenil reverses benzodiazepine sedation. Why is it used with caution in patients who take benzodiazepines long-term?
AIt makes the benzodiazepine effect much stronger
BIt can cause sudden withdrawal and seizures
CIt causes permanent memory loss after a single dose
DIt causes a dangerous rise in blood sugar
24.Mental health nursingHard
After her house burned down, a woman developed delusions and disorganised speech. Ten days later the symptoms have gone completely and she is back to normal. Which diagnosis best fits?
ASchizophrenia
BSchizophreniform disorder
CBrief psychotic disorder
DDelusional disorder
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A drip-rate calculation gives 145.233 gtt/min. The rule in this exercise is that drip rates are rounded to the nearest whole drop. What value x do you record?
145.233 gtt/min
x = gtt/min
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion delivers 1 mg/h. Express this dose rate D in mcg/min. Round to one decimal place.
1 mg/h1 mg = 1000 mcg1 h = 60 min
D = mcg/min
27.Dosage calculationsMedium
A patient weighing 61 kg has a body surface area of 1.52 m². The prescription is 375 mg/m². Find the dose D in mg.
61 kgBSA = 1.52 m²375 mg/m²
D = mg
28.Dosage calculationsHard
A child weighing 20 kg is prescribed 5 mg/kg per dose of an oral suspension that contains 40 mg in 1 mL. What volume V do you give?
20 kg5 mg/kg40 mg/1 mL
V = mL
29.IV infusion ratesMedium
Infuse 250 mL over 4 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
250 mL4 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
500 mg of a drug is diluted in 500 mL and given by gravity through a set of 60 gtt/mL. The order is 100 mg per hour. Find the drip rate R in drops per minute.
500 mg/500 mL100 mg/h60 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 50 units of regular insulin in 50 mL. The order is 0.1 units/kg/h for a patient who weighs 86 kg. Find the pump rate R in mL/h. Round to one decimal place.
50 units/50 mL0.1 units/kg/h86 kg
R = mL/h
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 10 mcg/kg/min for a patient who weighs 79 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL10 mcg/kg/min79 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 63 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 06:00 and runs by pump at 150 mL/h. How many mL V are left in the bag at 08:00?
500 mL150 mL/h06:00 → 08:00
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: yes; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: no; gait: normal, bed rest or wheelchair; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 60 mmHg. A patient’s systolic pressure is 82 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 60 mmHg?
MAP 60 mmHgSBP 82 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.53, PaCO₂ 20 mmHg (2.7 kPa) and HCO₃⁻ 16 mmol/L. The primary disorder is respiratory alkalosis. How far is it compensated? Click your answer.
pH 7.53PaCO₂ 20 mmHg (2.7 kPa)HCO₃⁻ 16 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 135, Cl⁻ 105 and HCO₃⁻ 14 mmol/L. Calculate the delta ratio (AG − 12)/(24 − HCO₃⁻), using AG = Na⁺ − (Cl⁻ + HCO₃⁻). Give two decimals.
Na⁺ 135 mmol/LCl⁻ 105 mmol/LHCO₃⁻ 14 mmol/L
delta ratio =
39.ECG rhythm strip interpretationMedium
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 bradycardia
2atrial flutter, 2:1 conduction
3normal sinus rhythm
4sinus tachycardia
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
1supraventricular tachycardia (SVT)
2atrial flutter, 2:1 conduction
3atrial fibrillation
4ventricular tachycardia
3Solutions
1.Nursing fundamentals
Answer: B · That they know how and when to take them and what to report
Why this is the answer
Safe discharge needs the patient or carer to understand dose, timing, purpose and important side effects. Teach-back and written information help confirm this.
Answer
B · That they know how and when to take them and what to report
2.Nursing fundamentals
Answer: A · It can cause a fatal cardiac arrest
Why this is the answer
A sudden rise in blood potassium can stop the heart. IV potassium is given diluted, by a controlled infusion and following strict policy, which is why concentrated forms are tightly controlled.
Answer
A · It can cause a fatal cardiac arrest
3.Infection control & patient safety
Answer: D · Postpone the visit until the visitor is well
Why this is the answer
Patients with severe neutropenia cannot fight infections well. People with respiratory or other infections should not visit until they are well; other visitors perform hand hygiene.
Answer
D · Postpone the visit until the visitor is well
4.Infection control & patient safety
Answer: A · Notify the infection prevention team and place affected patients on contact precautions
Why this is the answer
Early reporting lets infection prevention organize testing, cohorting, closing of the ward if needed, cleaning with suitable agents and soap-and-water hand hygiene. Moving patients around can spread the outbreak.
Answer
A · Notify the infection prevention team and place affected patients on contact precautions
5.Prioritization & delegation
Answer: B · Say the nurse will come to answer, and tell the nurse
Why this is the answer
Patient teaching about medicines is a nursing responsibility. The assistant passes the question on to the nurse, so the patient gets accurate information that fits their situation.
Answer
B · Say the nurse will come to answer, and tell the nurse
6.Prioritization & delegation
Answer: C · The injury does not fit the infant’s development, so possible abuse must be reported
Why this is the answer
Most 2-month-olds cannot roll, and a spiral fracture in a non-mobile infant suggests a twisting force. Nurses must report suspected abuse according to law and policy.
Answer
C · The injury does not fit the infant’s development, so possible abuse must be reported
7.Clinical nursing
Answer: D · Kidney damage and hearing loss
Why this is the answer
Gentamicin is nephrotoxic and ototoxic. Blood levels and renal function are monitored, and any tinnitus, dizziness or hearing change is reported.
Answer
D · Kidney damage and hearing loss
8.Clinical nursing
Answer: C · APTT for heparin and INR for warfarin
Why this is the answer
The APTT reflects the intrinsic pathway and is used to adjust heparin infusions. Warfarin is monitored by the INR, a standardised prothrombin time. Platelets are also checked on heparin to detect HIT.
Answer
C · APTT for heparin and INR for warfarin
9.Lab values & electrolytes
Answer: A · Send the fluid for cell count and culture and report it
Why this is the answer
Cloudy effluent with abdominal pain suggests peritonitis, the main serious complication of peritoneal dialysis. A sample is sent for white cell count, Gram stain and culture, and antibiotics (often given in the dialysis fluid) are started as prescribed.Checked against:Dialysis - peritoneal · MedlinePlus (NIH) (2024)
Answer
A · Send the fluid for cell count and culture and report it
10.Lab values & electrolytes
Answer: A · Heparin is adjusted using the aPTT or anti-Xa level, not the INR
Why this is the answer
Unfractionated heparin infusions are adjusted using the aPTT or anti-factor Xa level according to protocol. The INR monitors warfarin and is little affected by heparin at usual doses. Using the wrong test can cause under- or over-anticoagulation.Checked against:Partial Thromboplastin Time (PTT) Test · MedlinePlus (NIH) (2026); Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024)
Answer
A · Heparin is adjusted using the aPTT or anti-Xa level, not the INR
11.Pharmacology
Answer: D · Draw up the clear regular insulin first, then the cloudy NPH insulin
Why this is the answer
Drawing up regular insulin first prevents NPH from contaminating the regular insulin vial. NPH is gently rolled, not shaken, to mix it.
Answer
D · Draw up the clear regular insulin first, then the cloudy NPH insulin
12.Pharmacology
Answer: C · Both raise cGMP in vascular smooth muscle and can cause severe hypotension
Why this is the answer
Nitrates increase cGMP production through nitric oxide and sildenafil blocks its breakdown by PDE5. Together they cause excessive vasodilation and a dangerous fall in blood pressure.
Answer
C · Both raise cGMP in vascular smooth muscle and can cause severe hypotension
13.Med-surg: cardiovascular & respiratory
Answer: A · To avoid delivering the shock during the T wave
Why this is the answer
A shock delivered on the T wave (the vulnerable period) can trigger ventricular fibrillation. Synchronisation times the shock to the R wave. In ventricular fibrillation there is no organised QRS, so defibrillation is unsynchronised.
Answer
A · To avoid delivering the shock during the T wave
14.Med-surg: cardiovascular & respiratory
Answer: A · Call for expert help and give oxygen to both the face and the stoma
Why this is the answer
In the first days after a tracheostomy, the tract is immature and the tube can easily be misplaced into the tissues. Emergency guidance is to call for an airway expert, apply oxygen to face and stoma and assess breathing. Reinsertion is done only by trained staff.
Answer
A · Call for expert help and give oxygen to both the face and the stoma
15.Med-surg: neuro, endocrine & renal
Answer: B · A patient with heart failure
Why this is the answer
Pioglitazone can cause fluid retention and oedema, which can worsen heart failure. It is contraindicated in patients with heart failure. Weight gain and an increased fracture risk are other effects.
Answer
B · A patient with heart failure
16.Med-surg: neuro, endocrine & renal
Answer: A · Nephrogenic DI caused by lithium
Why this is the answer
Lithium is a common cause of nephrogenic DI, in which the collecting ducts do not respond to ADH, so desmopressin has little effect. Management includes specialist review of the lithium, access to water and monitoring of sodium and lithium levels.
Answer
A · Nephrogenic DI caused by lithium
17.Med-surg: GI, perioperative & oncology
Answer: B · Chemo-tested gloves and impermeable gown
Why this is the answer
Cytotoxic drugs can be absorbed through skin or inhaled. Staff use chemotherapy-tested gloves (often double), impermeable long-sleeved gowns and eye protection where splashing could occur, along with closed-system devices and safe disposal.
Answer
B · Chemo-tested gloves and impermeable gown
18.Med-surg: GI, perioperative & oncology
Answer: D · Call for urgent anaesthetic help, as the airway is swelling
Why this is the answer
Progressive hoarseness and stridor after a facial or inhalation burn mean the airway is narrowing. Early intubation by an experienced anaesthetist is needed before swelling makes it impossible. The patient is sat up and given oxygen.
Answer
D · Call for urgent anaesthetic help, as the airway is swelling
19.Maternity & obstetric nursing
Answer: A · It appears later, after the first week, in a thriving baby
Why this is the answer
Breast milk jaundice begins after the first week and can last several weeks in an otherwise healthy, well-fed baby. It is thought to be caused by substances in milk and rarely needs breastfeeding to stop.
Answer
A · It appears later, after the first week, in a thriving baby
20.Maternity & obstetric nursing
Answer: A · A ferning pattern on a dried slide under the microscope
Why this is the answer
Amniotic fluid forms a fern-like pattern when dried and turns nitrazine paper blue because it is alkaline. Vaginal secretions and urine are usually acidic. Blood, semen and infection can give false positives on nitrazine testing.
Answer
A · A ferning pattern on a dried slide under the microscope
21.Pediatric nursing
Answer: C · Lock all medicines away, out of reach and sight, in child-resistant containers
Why this is the answer
Toddlers explore by climbing and putting things in their mouths. Medicines should be locked away and put back immediately after use. Calling medicine sweets encourages children to take it on their own.
Answer
C · Lock all medicines away, out of reach and sight, in child-resistant containers
22.Pediatric nursing
Answer: A · Headache, repeated vomiting and increasing drowsiness
Why this is the answer
Headache, vomiting, irritability and drowsiness suggest raised intracranial pressure from shunt blockage or infection. In infants, a bulging fontanelle and a rising head circumference are also signs.
Answer
A · Headache, repeated vomiting and increasing drowsiness
23.Mental health nursing
Answer: B · It can cause sudden withdrawal and seizures
Why this is the answer
Flumazenil is a benzodiazepine antagonist. In dependent patients, or in mixed overdoses with drugs that lower the seizure threshold, it can trigger acute withdrawal and seizures.
Answer
B · It can cause sudden withdrawal and seizures
24.Mental health nursing
Answer: C · Brief psychotic disorder
Why this is the answer
Brief psychotic disorder lasts at least 1 day but less than 1 month, followed by a full return to the previous level of functioning. It may follow a severe stressor.
Answer
C · Brief psychotic disorder
25.Nursing math & unit conversions
Answer: x = 145 gtt/min
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the ones place
145.233 → 5
Only the next digit decides
145.233 → 2
2 is 4 or less, so 5 stays.
The digits after it (33) are ignored: round once, never step by step.
Round
x = 145 gtt/min
Answer
x = 145 gtt/min
26.Nursing math & unit conversions
Answer: D = 16.7 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 = 1 mg/h × (1000 mcg/1 mg) × (1 h/60 min)
Calculate
D = 1000/60 = 16.67 ≈ 16.7 mcg/min
Answer
D = 16.7 mcg/min
27.Dosage calculations
Answer: D = 570 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).
Dose
D = 375·1.52 = 570 mg
Answer
D = 570 mg
28.Dosage calculations
Answer: V = 2.5 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose from weight
5·20 = 100 mg
Volume
V = (100/40)·1 = 2.5 mL
Answer
V = 2.5 mL
29.IV infusion rates
Answer: R = 10 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
4·60 = 240 min
Drip rate
R = 250·10/240 = 10.42 ≈ 10 gtt/min
Answer
R = 10 gtt/min
At the bedside you round to the nearest whole drop: 10 gtt/min.
30.IV infusion rates
Answer: R = 100 gtt/min
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
500/500 = 1 mg/mL
Volume per hour
100/1 = 100 mL/h
Drip rate
R = 100·60/60 = 100 gtt/min
Answer
R = 100 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 8.6 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
0.1·86 = 8.6 units/h
Concentration
50/50 = 1 units/mL
Pump rate
R = 8.6/1 = 8.6 mL/h
Answer
R = 8.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 29.6 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
10·79 = 790 mcg/min
790·60 = 47400 mcg/h
Pump rate
R = 47400/1600 = 29.63 ≈ 29.6 mL/h
Answer
R = 29.6 mL/h
33.IV fluids & fluid balance
Answer: U = 2.53 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 + 400 + 200 + 250 = 1275 mL
Per kilogram per hour
U = 1275/(63·8) = 2.53 mL/kg/h
Answer
U = 2.53 mL/kg/h
34.IV fluids & fluid balance
Answer: V = 200 mL
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Elapsed time
06:00 → 08:00 = 2 h
Volume infused
150·2 = 300 mL
Volume left
V = 500 − 300 = 200 mL
Answer
V = 200 mL
35.Clinical assessment scores
Answer: MFS = 55
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: no → 0
gait: normal, bed rest or wheelchair → 0
mental status: knows own limits → 0
Add
Morse total = 25 + 15 + 15 + 0 + 0 + 0 = 55
Answer
MFS = 55
36.Clinical assessment scores
Answer: DBP = 49 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·60 − 82)/2 = 98/2 = 49 mmHg
Answer
DBP = 49 mmHg
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 7.53: alkalaemia (above 7.45)
PaCO₂ 20 mmHg: low (35–45)
HCO₃⁻ 16 mmol/L: low (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: delta ratio = 0.4
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 = 135 − (105 + 14) = 16
Delta ratio
(16 − 12)/(24 − 14) = 4/10 = 0.4
Answer
delta ratio = 0.4
Below 1: an added normal anion gap acidosis.
39.ECG rhythm strip interpretation
Answer: sinus tachycardia
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: R–R = 13 small boxes, 1500 ÷ 13 ≈ 115 per minute.
2. Rhythm: regular, every R–R is 0.52 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
sinus tachycardia
Answer
sinus tachycardia
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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