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
What makes "Risk for falls" a risk nursing diagnosis rather than an actual one?
AThe patient has already fallen several times
BThe doctor has confirmed the diagnosis with tests and a scan
CThe fall has not happened yet, but risk factors are present
DThe problem can never be prevented
2.Nursing fundamentalsHard
An elderly patient on intravenous fluids becomes breathless, with crackles in the lungs and swollen ankles. What is the most likely problem?
AHypoglycaemia
BNormal response to IV fluids
CFluid overload
DDehydration
3.Infection control & patient safetyMedium
A patient walking with a gait belt suddenly starts to fall. What should the nurse do?
AGrab the patient under both arms and try hard to keep them standing up
BHold the belt, widen the stance and ease the patient gently to the floor
CPull the patient backwards quickly toward the bed
DLet go of the belt and run to call for help
4.Infection control & patient safetyHard
Two look-alike vials of different drugs are stored next to each other, and a nurse almost picks the wrong one. Which response best reflects a just culture?
ADiscipline the nurse who nearly picked the wrong vial
BTell the nurse to be more careful and do nothing else
CReport it and fix the system, for example by separating the vials
DKeep the incident quiet to protect the unit’s reputation
5.Prioritization & delegationMedium
Which nursing assistant task is appropriate for a patient two days after hip replacement?
ATeaching the patient the hip precautions before discharge
BChecking the incision for redness, warmth and drainage
CEvaluating whether the last dose of pain medication controlled the pain
DHelping the patient into a chair, following the hip precautions
6.Prioritization & delegationHard
After surgery, a patient who has taken long-term steroids becomes hypotensive and weak, and the blood pressure does not rise with IV fluids. Which problem should the nurse suspect?
ANormal tiredness after anesthesia
BFluid overload from too much IV fluid
CAn allergic reaction to the anesthetic
DAdrenal crisis from steroid withdrawal
7.Clinical nursingMedium
Which pattern is typical of relapsing–remitting multiple sclerosis?
ASudden severe headache with neck stiffness
BA single stroke that leaves permanent weakness
CAttacks of symptoms, such as visual loss or numbness, that improve between relapses
DConstant weakness that starts in the feet and spreads upwards after a viral illness
8.Clinical nursingHard
A patient with an epidural catheter develops new back pain and increasing leg weakness when the block should be wearing off. What should be suspected?
AAn epidural haematoma or abscess compressing the spinal cord
BMuscle strain from lying in the same position in bed for many hours
CMild hypokalaemia
DThe normal expected effect of the local anaesthetic
9.Lab values & electrolytesMedium
How should a patient collect a clean-catch midstream urine sample?
ACollect urine from the toilet bowl after voiding into the toilet
BCollect the very first urine of the stream directly in the sterile cup
CFill the cup completely, then add tap water if there is not enough
DClean the area, start voiding into the toilet, then catch the middle part
10.Lab values & electrolytesHard
A patient with chronic hyponatremia (sodium 118 mEq/L) is being treated. Why must the sodium be raised slowly?
AIt can cause osmotic demyelination, a serious brain injury
BRapid correction makes the sodium fall again even further
CRapid correction causes hypokalemia, which is the only risk
DSlow correction is needed only to reduce hospital costs
11.PharmacologyMedium
Why is simvastatin traditionally taken in the evening?
AIt causes too much drowsiness to be taken in the morning
BIt is inactivated by sunlight during the day
CIt is short-acting, and cholesterol synthesis peaks at night
DIt must be taken with the largest meal of the day
12.PharmacologyHard
Newborns given chloramphenicol can develop "grey baby syndrome". What is the main reason?
AChloramphenicol is converted to vitamin K in neonates
BImmature glucuronidation in the liver lets the drug accumulate
CThe newborn kidney excretes the drug too quickly, so higher doses are given
DNewborns produce antibodies against the drug
13.Med-surg: cardiovascular & respiratoryMedium
Rheumatic heart disease most often follows which infection?
AA group A streptococcal throat infection
BStaphylococcal infection of the skin
CA fungal infection of the lungs
DA viral infection of the upper airway
14.Med-surg: cardiovascular & respiratoryHard
A patient with rheumatoid arthritis is due to start an anti-TNF biologic drug. Which screening is essential beforehand?
AScreening for latent tuberculosis
BA peak flow diary for a month
CAn exercise ECG test on a treadmill
DA sweat chloride test
15.Med-surg: neuro, endocrine & renalMedium
Why does a patient with untreated hypothyroidism need extra care when given opioids or sedatives?
AThey break the drugs down slowly and are more sensitive to them
BThey clear the drugs too fast, so higher doses are needed
CThere is no difference compared with other patients
DThese drugs make the thyroid gland overactive
16.Med-surg: neuro, endocrine & renalHard
A patient on peritoneal dialysis notices that less fluid drains out than was put in. They have not opened their bowels for four days, and the effluent is clear. What is the most likely cause?
ABacterial peritonitis
BConstipation obstructing outflow
CNormal absorption with no action needed
DDialysate given too cold
17.Med-surg: GI, perioperative & oncologyMedium
Why is an ankle-brachial pressure index (ABPI) measured before compression bandaging for a leg ulcer?
ATo exclude significant arterial disease
BTo find out how deep the ulcer is
CTo check for a leg bone fracture
DTo find the bacteria in the wound
18.Med-surg: GI, perioperative & oncologyHard
An immobile patient on opioids drinks very little. Which laxative choice is least appropriate?
AA bulk-forming laxative used on its own
BA stimulant laxative taken regularly
CA stool softener with a stimulant laxative
DAn osmotic laxative such as a macrogol
19.Maternity & obstetric nursingMedium
During the hip examination, the nurse hears a "clunk" as the newborn's hip is abducted. What does this suggest?
AA normal finding in all newborns
BDevelopmental dysplasia of the hip
CA fractured femur from the birth
DClubfoot affecting the same side
20.Maternity & obstetric nursingHard
A newborn passed no meconium by 48 hours and has a swollen abdomen and green vomiting. Which condition should be suspected?
ADevelopmental hip dysplasia
BHirschsprung disease
CPhysiological jaundice
DErythema toxicum
21.Pediatric nursingMedium
When is the risk of bleeding after a tonsillectomy highest?
AIn the first 24 hours and again about 5 to 10 days later
BOnly during the first 2 hours after surgery
COnly after 3 weeks, when the throat is fully healed
DThe risk stays exactly the same on every day for the first month
22.Pediatric nursingHard
A 15-year-old with cystic fibrosis has stopped doing her daily physiotherapy. What is the best approach?
AWarn her firmly that she will die soon if she does not do what she is told
BExplore her reasons and plan treatment with her that fits her daily life
CStop the physiotherapy, since she does not want it
DTell her parents to supervise every session until she is 18
23.Mental health nursingMedium
What should a patient starting zolpidem for insomnia be taught to report?
ASleeping through the night without waking up
BDoing things while not fully awake, such as sleepwalking or driving, with no memory of it
CFeeling slightly more rested and alert the next morning than before starting the medicine
DFeeling sleepy about 30 minutes after taking it at bedtime
24.Mental health nursingHard
A behaviour plan states that staff will no longer give attention to a child's tantrums but will praise calm behaviour. For the first few days, the tantrums become worse. What does this most likely show?
AAn extinction burst, which is expected before the behaviour decreases
BThat the tantrums are caused by a physical illness
CThat the child needs firm punishment for each tantrum instead
DThat the plan has failed and should be stopped immediately
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A drip-rate calculation gives 144.117 gtt/min. The rule in this exercise is that drip rates are rounded to the nearest whole drop. What value x do you record?
144.117 gtt/min
x = gtt/min
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 18:15 and finishes at 05:10 the next morning (24-hour clock). How many minutes t did it run?
18:1505:10
t = min
27.Dosage calculationsMedium
An ampoule of epinephrine (adrenaline) is labelled 1:1000 (1 mg/mL). The prescription is 0.3 mg IM for anaphylaxis. What volume V do you draw up?
1:10000.3 mg
V = mL
28.Dosage calculationsHard
The prescription is 4500 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?
4500 units5000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 500 mL over 2 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL2 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
100 mg of a drug is diluted in 100 mL and given by gravity through a set of 60 gtt/mL. The order is 30 mg per hour. Find the drip rate R in drops per minute.
100 mg/100 mL30 mg/h60 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 100 units of regular insulin in 250 mL runs at 6 mL/h. How many units per hour D does the patient receive?
100 units/250 mL6 mL/h
D = units/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 800 mg in 500 mL. The order is 4 mcg/kg/min for a patient who weighs 91 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL4 mcg/kg/min91 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 fluid balance B = intake − output in mL (a negative answer means a net loss).
tea: 150 mLjelly: 100 mLIV infusion: 125 mL/h × 12 hIV antibiotic: 1 × 50 mLurine: 200 mLurine: 325 mL
B = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 19:00 at 75 mL/h. After 4 hours the rate is changed to 200 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL75 mL/h · 4 h200 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 7, with E1 and V3. What motor score M was recorded, and which response does it describe? Give the number.
GCS 7E1V3
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: very limited; moisture: very moist; activity: walks frequently; mobility: no limitation; nutrition: excellent; friction and shear: no apparent problem. Use the bands 19–23 not at risk, 15–18 mild, 13–14 moderate, 10–12 high and 9 or below very high. Click the risk level.
1not at risk
2mild risk
3moderate risk
4high risk
5very high risk
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.53, PaCO₂ 47 mmHg (6.3 kPa) and HCO₃⁻ 38 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.53PaCO₂ 47 mmHg (6.3 kPa)HCO₃⁻ 38 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a respiratory acidosis: pH 7.23, PaCO₂ 66 mmHg (8.8 kPa), HCO₃⁻ 27 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 7.23PaCO₂ 66 mmHg (8.8 kPa)HCO₃⁻ 27 mmol/L
1acute
2chronic
3acute on chronic
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
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
1dual-chamber (AV) paced rhythm
2ventricular paced rhythm
3third-degree (complete) AV block
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: C · The fall has not happened yet, but risk factors are present
Why this is the answer
A risk diagnosis describes a problem the patient is vulnerable to, based on risk factors, with no signs yet. Care aims to prevent the problem from occurring.
Answer
C · The fall has not happened yet, but risk factors are present
2.Nursing fundamentals
Answer: C · Fluid overload
Why this is the answer
Breathlessness, crackles, raised respiratory rate and oedema during IV therapy suggest fluid overload. The nurse should stop or slow the infusion as appropriate, sit the patient up and escalate.
Answer
C · Fluid overload
3.Infection control & patient safety
Answer: B · Hold the belt, widen the stance and ease the patient gently to the floor
Why this is the answer
The nurse keeps hold of the gait belt, takes a wide base of support and slides the patient down along their own leg to the floor, protecting the head. This controls the fall and protects the nurse’s back.
Answer
B · Hold the belt, widen the stance and ease the patient gently to the floor
4.Infection control & patient safety
Answer: C · Report it and fix the system, for example by separating the vials
Why this is the answer
A just culture recognizes that human errors are often caused by system design. Separating look-alike drugs, using labels and Tall Man lettering prevents repeats. Blaming the person alone leaves the hazard in place.
Answer
C · Report it and fix the system, for example by separating the vials
5.Prioritization & delegation
Answer: D · Helping the patient into a chair, following the hip precautions
Why this is the answer
Helping a stable patient move, using precautions already set in the care plan, is a routine task. Inspecting the wound, teaching and evaluating pain relief need nursing assessment.
Answer
D · Helping the patient into a chair, following the hip precautions
6.Prioritization & delegation
Answer: D · Adrenal crisis from steroid withdrawal
Why this is the answer
Patients on long-term steroids may not make enough cortisol to cope with surgical stress. Refractory hypotension suggests adrenal crisis, which needs urgent IV hydrocortisone as prescribed.
Answer
D · Adrenal crisis from steroid withdrawal
7.Clinical nursing
Answer: C · Attacks of symptoms, such as visual loss or numbness, that improve between relapses
Why this is the answer
MS causes demyelination in the brain and spinal cord. Many patients first have attacks such as optic neuritis or sensory symptoms, with partial or full recovery between relapses.
Answer
C · Attacks of symptoms, such as visual loss or numbness, that improve between relapses
8.Clinical nursing
Answer: A · An epidural haematoma or abscess compressing the spinal cord
Why this is the answer
Increasing motor block, back pain or new weakness after an epidural can mean a haematoma or abscess compressing the cord. This is a surgical emergency: stop the infusion and get urgent medical review.
Answer
A · An epidural haematoma or abscess compressing the spinal cord
9.Lab values & electrolytes
Answer: D · Clean the area, start voiding into the toilet, then catch the middle part
Why this is the answer
Cleaning the urethral area and discarding the first part of the stream reduce contamination from skin and urethral bacteria. The inside of the sterile container must not be touched, and the sample should reach the laboratory promptly.Checked against:Clean catch urine sample · MedlinePlus (NIH) (2024)
Answer
D · Clean the area, start voiding into the toilet, then catch the middle part
10.Lab values & electrolytes
Answer: A · It can cause osmotic demyelination, a serious brain injury
Why this is the answer
When hyponatremia develops slowly, brain cells adapt. Raising the sodium too fast shrinks them and can damage the myelin of nerve cells (osmotic demyelination). Many guidelines limit the rise to about 8–10 mEq/L in 24 hours.Checked against:Osmotic demyelination syndrome · MedlinePlus (NIH) (2026)
Answer
A · It can cause osmotic demyelination, a serious brain injury
11.Pharmacology
Answer: C · It is short-acting, and cholesterol synthesis peaks at night
Why this is the answer
The liver makes most cholesterol overnight, and short-acting statins such as simvastatin work best when taken in the evening. Atorvastatin and rosuvastatin can be taken at any time of day.
Answer
C · It is short-acting, and cholesterol synthesis peaks at night
12.Pharmacology
Answer: B · Immature glucuronidation in the liver lets the drug accumulate
Why this is the answer
Neonates have low glucuronyl transferase activity, so chloramphenicol is not conjugated and builds up. High levels cause circulatory collapse with grey skin. It shows how organ immaturity changes pharmacokinetics.
Answer
B · Immature glucuronidation in the liver lets the drug accumulate
13.Med-surg: cardiovascular & respiratory
Answer: A · A group A streptococcal throat infection
Why this is the answer
Rheumatic fever is an autoimmune reaction weeks after group A streptococcal pharyngitis. It can permanently damage heart valves, most often the mitral valve. Prompt antibiotic treatment of strep throat prevents it.
Answer
A · A group A streptococcal throat infection
14.Med-surg: cardiovascular & respiratory
Answer: A · Screening for latent tuberculosis
Why this is the answer
TNF-alpha is essential for containing TB in granulomas. Anti-TNF drugs can reactivate latent TB, sometimes as severe disseminated disease. Patients are screened (history, chest X-ray, IGRA) and treated for latent TB before starting.
Answer
A · Screening for latent tuberculosis
15.Med-surg: neuro, endocrine & renal
Answer: A · They break the drugs down slowly and are more sensitive to them
Why this is the answer
In hypothyroidism, drug metabolism is slowed, and patients are more sensitive to sedatives and opioids. These drugs can cause respiratory depression and may even trigger myxoedema coma, so they are used with caution.
Answer
A · They break the drugs down slowly and are more sensitive to them
16.Med-surg: neuro, endocrine & renal
Answer: B · Constipation obstructing outflow
Why this is the answer
Poor outflow is often caused by constipation, catheter kinking or catheter displacement. Changing position, checking clamps and tubing and treating constipation often help; it should be reported. If it persists, imaging checks the catheter position. Clear effluent makes peritonitis less likely.
Answer
B · Constipation obstructing outflow
17.Med-surg: GI, perioperative & oncology
Answer: A · To exclude significant arterial disease
Why this is the answer
ABPI compares ankle and arm systolic pressures. A low ABPI suggests arterial disease, where compression could cause ischaemia, so assessment is needed before compression therapy.
Answer
A · To exclude significant arterial disease
18.Med-surg: GI, perioperative & oncology
Answer: A · A bulk-forming laxative used on its own
Why this is the answer
Bulk-forming laxatives need good fluid intake and mobility and can worsen constipation or cause obstruction without them. They do not counter the effect of opioids on gut movement, so stimulant or osmotic laxatives are preferred.
Answer
A · A bulk-forming laxative used on its own
19.Maternity & obstetric nursing
Answer: B · Developmental dysplasia of the hip
Why this is the answer
A clunk with the Ortolani or Barlow manoeuvre suggests a dislocated or dislocatable hip. Asymmetrical skin folds and limited abduction are other signs. Early ultrasound and treatment give good results.
Answer
B · Developmental dysplasia of the hip
20.Maternity & obstetric nursing
Answer: B · Hirschsprung disease
Why this is the answer
Delayed meconium, abdominal distension and bilious vomiting suggest bowel obstruction, such as Hirschsprung disease. Bilious vomiting in a newborn is always an emergency.
Answer
B · Hirschsprung disease
21.Pediatric nursing
Answer: A · In the first 24 hours and again about 5 to 10 days later
Why this is the answer
Primary bleeding occurs in the first 24 hours. Secondary bleeding occurs around 5–10 days after surgery, when the scabs come away, so families need to know the warning signs before going home.
Answer
A · In the first 24 hours and again about 5 to 10 days later
22.Pediatric nursing
Answer: B · Explore her reasons and plan treatment with her that fits her daily life
Why this is the answer
Adherence often falls in adolescence as young people seek independence and normality. Exploring barriers, involving the teenager in decisions, setting goals together and fitting treatment around school and friends work better than threats.
Answer
B · Explore her reasons and plan treatment with her that fits her daily life
23.Mental health nursing
Answer: B · Doing things while not fully awake, such as sleepwalking or driving, with no memory of it
Why this is the answer
Zolpidem and similar "Z-drugs" can cause complex sleep behaviours, such as sleep-walking, sleep-driving or cooking while not fully awake, which can cause serious injury. These must be reported and the drug stopped.
Answer
B · Doing things while not fully awake, such as sleepwalking or driving, with no memory of it
24.Mental health nursing
Answer: A · An extinction burst, which is expected before the behaviour decreases
Why this is the answer
When a reinforced behaviour stops being rewarded, it often increases temporarily (an extinction burst) before declining. Consistency by all staff is essential, while safety is always maintained.
Answer
A · An extinction burst, which is expected before the behaviour decreases
25.Nursing math & unit conversions
Answer: x = 144 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
144.117 → 4
Only the next digit decides
144.117 → 1
1 is 4 or less, so 4 stays.
The digits after it (17) are ignored: round once, never step by step.
Round
x = 144 gtt/min
Answer
x = 144 gtt/min
26.Nursing math & unit conversions
Answer: t = 655 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
18:15 → 24:00 = 345 min
After midnight
00:00 → 05:10 = 310 min
Total
t = 345 + 310 = 655 min
Answer
t = 655 min
27.Dosage calculations
Answer: V = 0.3 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Concentration
1:1000 = 1 g/1000 mL = 1 mg/mL
Volume
V = 0.3/1 = 0.3 mL
Answer
V = 0.3 mL
US labels now state mg/mL (1 mg/mL = 1:1000; 0.1 mg/mL = 1:10 000). Never give 1 mg/mL epinephrine IV push.
28.Dosage calculations
Answer: V = 0.9 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 = 4500/5000 = 0.9 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.9 mL
29.IV infusion rates
Answer: R = 42 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
2·60 = 120 min
Drip rate
R = 500·10/120 = 41.67 ≈ 42 gtt/min
Answer
R = 42 gtt/min
At the bedside you round to the nearest whole drop: 42 gtt/min.
30.IV infusion rates
Answer: R = 30 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
100/100 = 1 mg/mL
Volume per hour
30/1 = 30 mL/h
Drip rate
R = 30·60/60 = 30 gtt/min
Answer
R = 30 gtt/min
31.Pediatric & critical-care dosing
Answer: D = 2.4 units/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.
Concentration
100/250 = 0.4 units/mL
Units per hour
D = 6·0.4 = 2.4 units/h
Answer
D = 2.4 units/h
32.Pediatric & critical-care dosing
Answer: R = 13.7 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
800 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
4·91 = 364 mcg/min
364·60 = 21840 mcg/h
Pump rate
R = 21840/1600 = 13.65 ≈ 13.7 mL/h
Answer
R = 13.7 mL/h
33.IV fluids & fluid balance
Answer: B = 1275 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total intake
oral: 150 + 100 = 250 mL
IV infusion: 125·12 = 1500 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1800 mL
Total output
200 + 325 = 525 mL
Balance
B = 1800 − 525 = 1275 mL
Answer
B = 1275 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 5 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
75·4 = 300 mL
500 − 300 = 200 mL left
Second part
200/200 = 1 h
Total time
t = 4 + 1 = 5 h
Answer
t = 5 h
That is about 5 h 00 min, so the bag runs out at about 00:00.
35.Clinical assessment scores
Answer: M = 3
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Motor score
M = 7 − 1 − 3 = 3
M3: abnormal flexion of the arms (decorticate posture)
Answer
M = 3
36.Clinical assessment scores
Answer: not at risk
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: very limited → 2
moisture: very moist → 2
activity: walks frequently → 4
mobility: no limitation → 4
nutrition: excellent → 4
friction and shear: no apparent problem → 3
Add
Braden total = 2 + 2 + 4 + 4 + 4 + 3 = 19
Risk level
19 → not at risk
Answer
not at risk
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 47 mmHg: high (35–45)
HCO₃⁻ 38 mmol/L: high (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 + 1·2.6 = 26.6 mmol/L
chronic: 24 + 3.5·2.6 = 33.1 mmol/L
Compare
measured: 27 mmol/L → acute
Answer
acute
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: 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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