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
A patient is at high risk of falling. Which measure is most appropriate?
AGive a sedative at night
BKeep the bed low, the call bell within reach and non-slip footwear on
CRaise all bed rails routinely and keep the patient in bed until reviewed
DRestrict the patient to bed without assessment
2.Nursing fundamentalsHard
A patient standing for the first time after surgery becomes pale, sweaty and dizzy. What should the nurse do first?
AGive the patient a sugary drink while standing
BEncourage the patient to keep walking to build strength
CHelp the patient sit or lie down safely
DLeave the patient standing and fetch the blood pressure machine
3.Infection control & patient safetyMedium
Which nursing care reduces the risk of ventilator-associated pneumonia?
ARegular oral care to reduce bacteria in the mouth
BLying the patient flat for most of the day
CChanging the ventilator circuit every few hours
DLeaving secretions in the mouth to protect the airway
4.Infection control & patient safetyHard
A woman in late pregnancy is choking and cannot speak or cough. Which technique should the rescuer use?
ABack blows only
BAbdominal thrusts
CBlind finger sweeps
DChest thrusts
5.Prioritization & delegationMedium
A drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?
ATurn the patient onto their side
BGive a drink of water
CRaise the legs above the heart
DGive an oral anti-sickness tablet
6.Prioritization & delegationHard
During START triage, an adult is not breathing. The airway is repositioned and the victim still does not breathe. What is the correct category?
ARed, and start CPR at once
BYellow, and come back later
CBlack (deceased or expectant)
DRed, because no breathing is the most urgent finding
7.Clinical nursingMedium
A blood transfusion is about to start. What is the most important safety check?
APositive patient identification matched to the blood component at the bedside
BChecking the patient's dietary preferences
CChecking the patient's weight only
DWarming all blood in a microwave
8.Clinical nursingHard
A patient with a COPD exacerbation remains acidotic with a high PaCO2 despite optimal medical treatment and controlled oxygen. Which treatment is usually considered next?
A15 L/min oxygen via a non-rebreathe mask
BNon-invasive ventilation
CSedation to slow the breathing
DStopping all oxygen therapy
9.Lab values & electrolytesMedium
A trauma patient receives 2 L of IV crystalloid. The hemoglobin falls from 13.0 to 11.4 g/dL (130 to 114 g/L), and the vital signs are now stable. Which explanation is most likely?
AIncreased red cell production
BDilution of the blood by the IV fluid
CA laboratory error in the first sample
DA sudden failure of the bone marrow
10.Lab values & electrolytesHard
A 5-year-old has new bruising and petechiae two weeks after a viral illness. Platelets are 12 × 10³/µL; hemoglobin, white cell count and clotting times are normal. Which condition is most likely?
AImmune thrombocytopenia (ITP)
BHemophilia A
CAcute leukemia
DDisseminated intravascular coagulation
11.PharmacologyMedium
Which adverse effect is a well-known risk of zidovudine?
ABone marrow suppression, especially anaemia
BRed–green colour blindness
CGum overgrowth
DOrange-red colouring of the urine and tears
12.PharmacologyHard
A drug has a volume of distribution of 40 L and complete bioavailability. Which loading dose gives a target plasma concentration of 2 mg/L?
A160 mg
B80 mg
C42 mg
D20 mg
13.Med-surg: cardiovascular & respiratoryMedium
Which foot care advice is correct for a patient with peripheral arterial disease?
ACut corns with a razor blade to prevent pressure
BCheck the feet daily and wear well-fitting shoes
CWalk barefoot at home to strengthen the feet
DUse a hot water bottle on the feet at night
14.Med-surg: cardiovascular & respiratoryHard
A patient is going home after a spontaneous pneumothorax treated with a chest drain. Which advice is correct?
AExpect it never to happen again, so no follow-up is needed
BFly home as soon as possible so they can recover in comfort there
CTake up scuba diving to strengthen the lungs
DStop smoking and do not fly until a doctor confirms full resolution
15.Med-surg: neuro, endocrine & renalMedium
A bladder scan straight after voiding shows 450 mL of urine still in the bladder. What does this show?
AThe patient is passing urine normally
BThe patient has drunk too little fluid
CThe bladder is not emptying properly
DThe kidneys are making too little urine
16.Med-surg: neuro, endocrine & renalHard
A patient with a stroke and right-sided weakness is ready to transfer from bed to chair. Which approach is safest?
AAsk the patient to stand alone and walk to the chair
BPull the patient up by the right shoulder and wrist
CPlace the chair on the left side and pivot towards it
DPlace the chair on the right and lift by the weak arm
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
A patient with recurrent diverticulitis reports passing air and faecal matter in the urine. What is the most likely cause?
AA simple lower urinary tract infection
BA fistula between the colon and the bladder
CBowel preparation that was taken too quickly
DA kidney stone blocking the ureter
19.Maternity & obstetric nursingMedium
A woman with pre-eclampsia is on magnesium sulfate. Why does the nurse monitor her urine output closely?
AMagnesium is cleared by the kidneys, so oliguria raises the risk of toxicity
BMagnesium causes a large diuresis that leads to dehydration
CUrine output tells the nurse exactly when to stop the infusion after the birth
DLow urine output shows that the magnesium is working
20.Maternity & obstetric nursingHard
Which finding in a woman 2 hours after birth requires the most urgent follow-up?
AModerate lochia rubra with a few small clots
BTemperature 37.6 °C and shivering
CFundus firm and 1 cm below the umbilicus
DHeart rate 124/min with cool, clammy skin
21.Pediatric nursingMedium
How should the nurse position the ear when giving ear drops to a 2-year-old?
APull the pinna gently down and back
BPull the earlobe gently forward and up
CLeave the pinna alone and tilt the head
DPull the pinna gently up and back
22.Pediatric nursingHard
Which IV fluid is usually used for a fluid bolus in a child with shock?
AAn isotonic crystalloid such as 0.9% sodium chloride
B10% glucose solution
C0.18% sodium chloride with 4% glucose, given quickly
D5% glucose in water, given as fast as possible
23.Mental health nursingMedium
Which factor is one of the strongest predictors of future suicide?
AHaving a strong religious faith
BA previous suicide attempt
CHaving a stable job
DBeing married
24.Mental health nursingHard
A 15-year-old tells the school nurse she has been cutting herself and asks her not to tell her parents. What is the best response?
APromise never to tell anyone about it, so that she keeps trusting the school nurse
BExplain that safety information must be shared, and involve her in how this is done
CTell her that cutting is a phase that many teenagers go through and it needs no help
DPhone her parents at once without telling her
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 4 ft 0 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
4 ft 0 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A serum creatinine result is 1.1 mg/dL. Using 1 mg/dL = 88.4 µmol/L for creatinine, find c in µmol/L to the nearest whole number.
1.1 mg/dL1 mg/dL = 88.4 µmol/L
c = µmol/L
27.Dosage calculationsMedium
A vial contains 1 g of powder. The label says: add 4.2 mL of water for injection to give a total volume of 5 mL. The prescription is 240 mg. What volume V of the reconstituted solution do you give?
1 g+ 4.2 mL → 5 mL240 mg
V = mL
28.Dosage calculationsHard
A patient is 160 cm tall and weighs 70 kg. The prescription is 135 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
160 cm70 kg135 mg/m²
D = mg
29.IV infusion ratesMedium
An infusion is ordered at 120 mL/h, but no pump is available. It runs by gravity through a giving set of 20 gtt/mL. Find the drip rate R in drops per minute.
120 mL/h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 28 gtt/min through a set of 20 gtt/mL. There are 450 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
28 gtt/min20 gtt/mL450 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 12 500 units of heparin in 250 mL. The order is 12 units/kg/h for a patient who weighs 74 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
12 500 units/250 mL12 units/kg/h74 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dopamine infusion of 400 mg in 250 mL runs at 4 mL/h. The patient weighs 51 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
400 mg/250 mL4 mL/h51 kg
D = mcg/kg/min
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 07:30 at 80 mL/h. After 3 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 mL80 mL/h · 3 h200 mL/h
t = h
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: yes; gait: impaired; 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). An adult weighs 142 kg and is 173 cm tall. Calculate the BMI and click the WHO weight category.
142 kg173 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 12 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 12 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
A practice gas shows pH 7.25, PaCO₂ 19 mmHg (2.5 kPa) and HCO₃⁻ 8 mmol/L, with Na⁺ 132 and Cl⁻ 88 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
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
Interpret this lead II strip with the five steps in order: rate, rhythm, P waves, PR interval, QRS duration. At which step do you find the first abnormal finding? Click it.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1rate
2rhythm
3P waves
4PR interval
5QRS duration
3Solutions
1.Nursing fundamentals
Answer: B · Keep the bed low, the call bell within reach and non-slip footwear on
Why this is the answer
Standard fall prevention includes a low bed, call bell and personal items within reach, good lighting, footwear and regular checks. Bed rails and sedation need an individual assessment.
Answer
B · Keep the bed low, the call bell within reach and non-slip footwear on
2.Nursing fundamentals
Answer: C · Help the patient sit or lie down safely
Why this is the answer
These signs suggest postural hypotension and a risk of fainting. The nurse lowers the patient safely first, then checks blood pressure and pulse and reports the finding.
Answer
C · Help the patient sit or lie down safely
3.Infection control & patient safety
Answer: A · Regular oral care to reduce bacteria in the mouth
Why this is the answer
Oral care, including tooth brushing, reduces the bacteria that can be aspirated around the endotracheal tube. It is part of ventilator care along with head elevation and sedation review.
Answer
A · Regular oral care to reduce bacteria in the mouth
4.Infection control & patient safety
Answer: D · Chest thrusts
Why this is the answer
For people in late pregnancy or who are very obese, chest thrusts replace abdominal thrusts because the rescuer cannot get around the abdomen effectively. Blind finger sweeps can push the object deeper.
Answer
D · Chest thrusts
5.Prioritization & delegation
Answer: A · Turn the patient onto their side
Why this is the answer
A drowsy patient who vomits can aspirate. Turning them to the side lets vomit drain from the mouth; suction and a prescribed antiemetic follow.
Answer
A · Turn the patient onto their side
6.Prioritization & delegation
Answer: C · Black (deceased or expectant)
Why this is the answer
In START, a victim who does not breathe after the airway is repositioned is tagged black. CPR for one person would take rescuers away from many others who could survive. If breathing starts after repositioning, the victim is red.
Answer
C · Black (deceased or expectant)
7.Clinical nursing
Answer: A · Positive patient identification matched to the blood component at the bedside
Why this is the answer
The patient's identity on the wristband is checked against the compatibility label and prescription at the bedside. Baseline observations are taken before starting.
Answer
A · Positive patient identification matched to the blood component at the bedside
8.Clinical nursing
Answer: B · Non-invasive ventilation
Why this is the answer
In hypercapnic respiratory failure from COPD that persists despite treatment, non-invasive ventilation (bilevel positive pressure) supports ventilation and lowers PaCO2. Stopping oxygen would cause dangerous hypoxia.
Answer
B · Non-invasive ventilation
9.Lab values & electrolytes
Answer: B · Dilution of the blood by the IV fluid
Why this is the answer
IV fluids dilute the blood, so the hemoglobin falls even without further bleeding. Ongoing bleeding must still be considered, so vital signs, wounds and repeat hemoglobin values are monitored.
Answer
B · Dilution of the blood by the IV fluid
10.Lab values & electrolytes
Answer: A · Immune thrombocytopenia (ITP)
Why this is the answer
ITP is immune destruction of platelets, often after a viral infection in children. It causes isolated thrombocytopenia with normal other counts and clotting tests. Leukemia usually affects other cell lines, DIC prolongs clotting times and hemophilia prolongs the aPTT.Checked against:Immune thrombocytopenic purpura (ITP) · MedlinePlus (NIH) (2026)
Answer
A · Immune thrombocytopenia (ITP)
11.Pharmacology
Answer: A · Bone marrow suppression, especially anaemia
Why this is the answer
Zidovudine, a nucleoside reverse transcriptase inhibitor, can cause anaemia and neutropenia. Blood counts are checked regularly during treatment.
Answer
A · Bone marrow suppression, especially anaemia
12.Pharmacology
Answer: B · 80 mg
Why this is the answer
Loading dose = 40 L × 2 mg/L = 80 mg. The loading dose depends on Vd, while the maintenance dose depends on clearance.
Answer
B · 80 mg
13.Med-surg: cardiovascular & respiratory
Answer: B · Check the feet daily and wear well-fitting shoes
Why this is the answer
Reduced blood flow slows healing, so minor injuries can become ulcers or gangrene. Patients inspect their feet daily, keep them clean and moisturised, wear well-fitting footwear and see a podiatrist for nails and corns. Direct heat can burn ischaemic skin.
Answer
B · Check the feet daily and wear well-fitting shoes
14.Med-surg: cardiovascular & respiratory
Answer: D · Stop smoking and do not fly until a doctor confirms full resolution
Why this is the answer
Patients should not fly until the pneumothorax has resolved on X-ray, often with an extra waiting period. Diving is usually avoided permanently unless definitive surgery has been done. Smoking increases recurrence, which is common, so patients learn to seek help for new breathlessness or chest pain.
Answer
D · Stop smoking and do not fly until a doctor confirms full resolution
15.Med-surg: neuro, endocrine & renal
Answer: C · The bladder is not emptying properly
Why this is the answer
A large post-void residual means incomplete emptying, for example from obstruction or a weak detrusor. It raises the risk of infection and overflow incontinence and may need intermittent catheterisation or treatment of the cause.
Answer
C · The bladder is not emptying properly
16.Med-surg: neuro, endocrine & renal
Answer: C · Place the chair on the left side and pivot towards it
Why this is the answer
Transfers are safer towards the stronger side, so the patient can bear weight and pivot on the good leg. Pulling on a weak arm can cause shoulder subluxation and pain. Physiotherapy advice and appropriate aids should be followed.
Answer
C · Place the chair on the left side and pivot towards it
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: B · A fistula between the colon and the bladder
Why this is the answer
Pneumaturia and faecaluria suggest a colovesical fistula, a recognised complication of diverticulitis (and Crohn's disease or cancer). Recurrent urinary infections are common, and surgery is usually needed.
Answer
B · A fistula between the colon and the bladder
19.Maternity & obstetric nursing
Answer: A · Magnesium is cleared by the kidneys, so oliguria raises the risk of toxicity
Why this is the answer
Magnesium is cleared by the kidneys, so oliguria, which is common in pre-eclampsia, allows levels to rise. The nurse also monitors reflexes, respiratory rate and level of consciousness.
Answer
A · Magnesium is cleared by the kidneys, so oliguria raises the risk of toxicity
20.Maternity & obstetric nursing
Answer: D · Heart rate 124/min with cool, clammy skin
Why this is the answer
Tachycardia with cool, clammy skin is an early sign of hypovolaemia from hidden or ongoing bleeding. A firm fundus and moderate lochia are normal, and mild temperature rise and shivering are common in the first 24 hours.
Answer
D · Heart rate 124/min with cool, clammy skin
21.Pediatric nursing
Answer: A · Pull the pinna gently down and back
Why this is the answer
In children under about 3 years the ear canal is short and angled upward, so the pinna is pulled down and back. In older children and adults it is pulled up and back.
Answer
A · Pull the pinna gently down and back
22.Pediatric nursing
Answer: A · An isotonic crystalloid such as 0.9% sodium chloride
Why this is the answer
Isotonic crystalloids such as 0.9% sodium chloride or balanced solutions are used for boluses because they expand intravascular volume. Hypotonic fluids such as 5% glucose move into cells and can cause hyponatraemia and brain swelling.
Answer
A · An isotonic crystalloid such as 0.9% sodium chloride
23.Mental health nursing
Answer: B · A previous suicide attempt
Why this is the answer
A previous attempt greatly raises the risk. Other risk factors include mental disorder, substance use, hopelessness, access to lethal means, recent loss and social isolation. Social support and reasons for living are protective.
Answer
B · A previous suicide attempt
24.Mental health nursing
Answer: B · Explain that safety information must be shared, and involve her in how this is done
Why this is the answer
Confidentiality has limits when there is risk of harm. The nurse explains this honestly, assesses risk and works with the young person on how and with whom information is shared, in line with safeguarding policy.
Answer
B · Explain that safety information must be shared, and involve her in how this is done
25.Nursing math & unit conversions
Answer: h = 122 cm
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Height in inches
4·12 + 0 = 48 in
Inches to centimetres
h = 48·2.54 = 121.9 ≈ 122 cm
Answer
h = 122 cm
26.Nursing math & unit conversions
Answer: c = 97 µmol/L
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Convert
c = 1.1·88.4 = 97.24 ≈ 97 µmol/L
Answer
c = 97 µmol/L
27.Dosage calculations
Answer: V = 1.2 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.
Concentration after mixing
1000 mg/5 mL = 200 mg/mL
Volume
V = 240/200 = 1.2 mL
Answer
V = 1.2 mL
28.Dosage calculations
Answer: D = 238.1 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
Body surface area
BSA = √(160·70/3600) = √3.111 = 1.764 m²
Dose
D = 135·1.764 = 238.1 mg
Answer
D = 238.1 mg
29.IV infusion rates
Answer: R = 40 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.
Millilitres per minute
120/60 = 2 mL/min
Drip rate
R = 2·20 = 40 gtt/min
Answer
R = 40 gtt/min
30.IV infusion rates
Answer: t = 5.4 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
28·60/20 = 84 mL/h
Time left
t = 450/84 = 5.357 ≈ 5.4 h
Answer
t = 5.4 h
31.Pediatric & critical-care dosing
Answer: R = 17.8 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
12·74 = 888 units/h
Concentration
12 500/250 = 50 units/mL
Pump rate
R = 888/50 = 17.76 ≈ 17.8 mL/h
Answer
R = 17.8 mL/h
32.Pediatric & critical-care dosing
Answer: D = 2.1 mcg/kg/min
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
400 000/250 = 1600 mcg/mL
Micrograms per minute
4·1600 = 6400 mcg/h
6400/60 = 106.7 mcg/min
Per kilogram
D = 106.7/51 = 2.092 ≈ 2.1 mcg/kg/min
Answer
D = 2.1 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = 720 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: 250 + 120 + 350 = 720 mL
IV infusion: 75·8 = 600 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1370 mL
Total output
225 + 425 = 650 mL
Balance
B = 1370 − 650 = 720 mL
Answer
B = 720 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 4.3 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
80·3 = 240 mL
500 − 240 = 260 mL left
Second part
260/200 = 1.3 h
Total time
t = 3 + 1.3 = 4.3 h
Answer
t = 4.3 h
That is about 4 h 18 min, so the bag runs out at about 11:48.
35.Clinical assessment scores
Answer: MFS = 95
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: yes → 20
gait: impaired → 20
mental status: knows own limits → 0
Add
Morse total = 25 + 15 + 15 + 20 + 20 + 0 = 95
Answer
MFS = 95
36.Clinical assessment scores
Answer: obesity class III
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 142/1.73² = 47.45
Category
obesity class III
Answer
obesity class III
37.Arterial blood gas interpretation
Answer: PaCO₂ = 26 mmHg
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.
Winter’s formula
PaCO₂ = 1.5·12 + 8 = 26 mmHg
range: 24–28 mmHg
Answer
PaCO₂ = 26 mmHg
38.Arterial blood gas interpretation
Answer: pure high-gap acidosis
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 = 132 − (88 + 8) = 36
Delta ratio
(36 − 12)/(24 − 8) = 1.5
pure high-gap acidosis
Answer
pure high-gap acidosis
39.ECG rhythm strip interpretation
Answer: QTc = 0.416 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 = 11 × 0.04 = 0.44 s
RR = 28 × 0.04 = 1.12 s
Bazett’s formula
QTc = 0.44/√1.12 = 0.44/1.058 = 0.416 s
Answer
QTc = 0.416 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (416 ms)
40.ECG rhythm strip interpretation
Answer: PR interval
Five steps for every strip: 1. rate (300 or 1500 method, or the 6-second method if irregular); 2. rhythm: are the R–R intervals equal; 3. P waves: present, upright in lead II, one before every QRS and all alike; 4. PR interval: 0.12–0.20 s and constant; 5. QRS duration: below 0.12 s. Only after the five steps name the rhythm. Normal sinus rhythm passes all five: 60–100/min, regular, upright P before every QRS, PR 0.12–0.20 s, QRS below 0.12 s.
Five steps
1. Rate: R–R = 22 small boxes, 1500 ÷ 22 ≈ 68 per minute.
2. Rhythm: regular, every R–R is 0.88 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.36 s, constant, longer than 0.20 s.
5. QRS: 0.10 s, narrow (below 0.12 s).
First abnormal step
PR interval → first-degree AV block
Answer
PR interval
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