Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
Why might a nurse use silence during a conversation with a patient?
AIt lets the nurse plan the next task
BIt ends the conversation politely
CIt gives the patient time to think and say more
DIt shows the patient that the nurse is busy and wants to move on
2.Nursing fundamentalsHard
A patient reports pain of 8/10 but is chatting calmly and has normal vital signs. What should the nurse do?
AAccept the report, assess further and offer analgesia
BTell the patient they cannot be in that much pain
CRecord a lower score because the patient looks comfortable and calm
DWithhold analgesia until the vital signs change
3.Infection control & patient safetyMedium
When should an N95 respirator be removed after caring for a patient on airborne precautions?
AStraight after entering the room
BNever; it is worn for the rest of the shift
CBefore taking off the gloves, inside the room
DAfter leaving the room and closing the door
4.Infection control & patient safetyHard
A patient is on contact precautions. Which task is appropriate for the nurse to delegate to assistive personnel?
ADeciding when the precautions can be stopped
BTeaching the family how to follow the precautions
CAssessing the wound for new signs of infection during the bath
DHelping the patient bathe while wearing a gown and gloves
5.Prioritization & delegationMedium
A nurse teaches a patient about sublingual nitroglycerin tablets. Which statement shows a need for further teaching?
A“I will keep the tablets in their original dark container.”
B“I may get a headache after taking a tablet.”
C“I will swallow the tablet with a glass of water.”
D“I will sit down before I take a tablet.”
6.Prioritization & delegationHard
A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?
AAsk a nursing assistant to do it instead
BDo it, because the provider gave the instruction
CDecline, explain why and suggest who can safely do it
DDo it just this once and promise the provider not to do it again
7.Clinical nursingMedium
Which assessment best detects compartment syndrome after a fractured leg is put in a cast?
AA strong pulse in the foot
BMild itching under the cast
CA warm, pink foot
DPain out of proportion to the injury, especially on passive stretch
8.Clinical nursingHard
A conscious patient with hypoglycaemia was given fast-acting carbohydrate. On re-check 15 minutes later the blood glucose is 3.6 mmol/L (65 mg/dL). What should the nurse do next?
ATake no action because the level is rising
BGive a dose of subcutaneous insulin
CGive another dose of fast-acting carbohydrate and recheck
DGive a long-acting carbohydrate snack only and recheck tomorrow
9.Lab values & electrolytesMedium
When do the blood counts usually reach their lowest point (nadir) after many standard chemotherapy regimens?
AAbout 6 months after treatment
BWithin 1–2 hours of treatment
COn the same day as treatment
DAbout 7–14 days after treatment
10.Lab values & electrolytesHard
A patient with blood pressure that is hard to control has a potassium of 2.9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?
APrimary hyperaldosteronism
BSyndrome of inappropriate ADH
CCentral diabetes insipidus
DPrimary adrenal insufficiency
11.PharmacologyMedium
Which adverse effect is typical of metoclopramide, especially in young people?
ADry cough
BLow blood glucose
CExtrapyramidal movement disorders such as acute dystonia
DSevere constipation
12.PharmacologyHard
Why can an ACE inhibitor cause acute kidney injury in a patient with bilateral renal artery stenosis?
AACE inhibitors constrict the afferent arteriole
BACE inhibitors are directly toxic to the proximal tubule cells in the kidney
CThe drug crystallises in the renal tubules
DGFR depends on angiotensin II constricting the efferent arteriole
13.Med-surg: cardiovascular & respiratoryMedium
After an acute coronary syndrome, a patient with a normal cholesterol level is prescribed a high-intensity statin. Why?
AStatins reduce further events whatever the starting cholesterol
BStatins are given after an ACS mainly to lower the blood pressure
CStatins work as painkillers for chest pain
DStatins are needed only if the cholesterol level is very high
14.Med-surg: cardiovascular & respiratoryHard
A nurse teaches a patient with heart failure who takes ramipril and spironolactone. Which statement shows a need for further teaching?
A"I will weigh myself every morning after I go to the toilet."
B"I will use a salt substitute instead of ordinary salt."
C"I will avoid ibuprofen for my joint pain."
D"I will call if I gain weight quickly or get more breathless."
15.Med-surg: neuro, endocrine & renalMedium
Why does a patient with untreated hypothyroidism need extra care when given opioids or sedatives?
AThey clear the drugs too fast, so higher doses are needed
BThere is no difference compared with other patients
CThese drugs make the thyroid gland overactive
DThey break the drugs down slowly and are more sensitive to them
16.Med-surg: neuro, endocrine & renalHard
A nurse teaches the family of a patient on insulin how to manage a severe hypo. Which statement shows a need for further teaching?
A"I will put her on her side and call an ambulance straight away."
B"If she is unconscious, I will pour juice into her mouth."
C"When she can swallow, I will give her a snack."
D"I will give the glucagon as I was shown."
17.Med-surg: GI, perioperative & oncologyMedium
Which statement correctly describes physical dependence on opioids?
AThe patient always craves the drug and misuses it despite harm
BWithdrawal occurs if the drug is stopped suddenly
CThe drug no longer has any side effects
DThe patient is allergic to opioids
18.Med-surg: GI, perioperative & oncologyHard
A nurse spills a small amount of a cytotoxic drug on the floor. What is the correct approach?
ALeave it to evaporate and keep people away for a few minutes
BWipe it with a paper towel and put it in the general waste bin
CUse the spill kit with PPE, clean up, bag as cytotoxic waste and report
DMop it up with the ward mop and rinse the mop in the sluice
19.Maternity & obstetric nursingMedium
Which newborn finding is commonly associated with Down syndrome?
ALong nails and peeling skin
BAbundant vernix and lanugo
CA single palmar crease and low tone
DA high-pitched cry and tremors
20.Maternity & obstetric nursingHard
A newborn whose mother had a fever and prolonged rupture of membranes is well at birth. Why does the nurse monitor this baby closely?
AThe baby has a higher risk of hip dysplasia
BThe baby is likely to be post-term
CThe baby has a higher risk of early sepsis
DThe baby will certainly develop jaundice
21.Pediatric nursingMedium
A toddler with hand, foot and mouth disease refuses to drink because of painful mouth sores. What is the priority?
ATreating the rash with steroid cream
BPreventing dehydration
CPreventing hair loss
DStarting antibiotics
22.Pediatric nursingHard
A toddler weighed 10 kg before 2 days of diarrhoea and now weighs 9.5 kg. How much has he lost?
A1 kg, about 10% of his body weight
B500 g, about 5% of his body weight, mostly fluid
C500 g, about 50% of his body weight
D50 g, about 0.5% of his body weight
23.Mental health nursingMedium
An 84-year-old asks for an over-the-counter sleep aid containing diphenhydramine. What is the main concern?
AIt has no effects at all in people over 80, so it will not help her sleep
BIts anticholinergic effects can cause confusion, urine retention and falls
CIt is a strong opioid that causes severe dependence
DIt raises blood pressure to dangerous levels in older adults
24.Mental health nursingHard
While caring for a highly anxious patient, a nurse notices her own heart racing and her speech getting faster. What is most important?
AMatch the patient's level of anxiety to show empathy
BIgnore her own reaction, because the nurse's feelings do not matter in patient care
CLeave the patient immediately and not return
DRecognise that anxiety spreads between people, and calm herself first
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A weight conversion gives 67.1247 kg. The rule in this exercise is that weights are rounded to the nearest tenth of a kilogram. What value x do you record?
67.1247 kg
x = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A maintenance infusion runs at 20 mL/h without a break. How many litres V does it deliver in 24 hours?
20 mL/h24 h
V = L
27.Dosage calculationsMedium
A child weighing 20 kg is prescribed 4 mg/kg of a drug. The stock solution contains 20 mg/mL. Draw up the dose: what volume V do you give?
20 kg4 mg/kg20 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 180 units of a drug that comes as 1000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
180 units1000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 5 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute.
1500 mL5 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 50 mg in 500 mL runs at 12 mL/h. How many micrograms per minute D does the patient receive?
50 mg/500 mL12 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 100 units of regular insulin in 100 mL runs at 3 mL/h. How many units per hour D does the patient receive?
100 units/100 mL3 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 89 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL4 mcg/kg/min89 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 09:00 and runs by pump at 120 mL/h. How many mL V are left in the bag at 10:30?
1000 mL120 mL/h09:00 → 10:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: no impairment; moisture: very moist; activity: chairfast; mobility: completely immobile; nutrition: very poor; friction and shear: no apparent problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 16/min, SpO₂ 99% on room air, blood pressure 96/58 mmHg, pulse 82/min, alert, temperature 38.1 °C. Which clinical risk group does the patient fall into? Click it.
RR 16SpO₂ 99%airSBP 96HR 82AT 38.1 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 8 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 8 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
A practice gas shows pH 7.29, PaCO₂ 28 mmHg (3.7 kPa) and HCO₃⁻ 13 mmol/L, with Na⁺ 144 and Cl⁻ 93 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
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
1normal sinus rhythm
2atrial flutter, 4:1 conduction
3atrial fibrillation
4sinus tachycardia
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. The QRS complexes are regular: find the ventricular rate in beats per minute (1500 method, whole number).
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
3Solutions
1.Nursing fundamentals
Answer: C · It gives the patient time to think and say more
Why this is the answer
Therapeutic silence gives the patient space to gather their thoughts and express feelings, especially about difficult topics. It is used with attentive body language.
Answer
C · It gives the patient time to think and say more
2.Nursing fundamentals
Answer: A · Accept the report, assess further and offer analgesia
Why this is the answer
Pain is what the patient says it is. People cope with pain in different ways, and vital signs often stay normal, especially in chronic pain, so the self-report guides care.
Answer
A · Accept the report, assess further and offer analgesia
3.Infection control & patient safety
Answer: D · After leaving the room and closing the door
Why this is the answer
Because infectious particles remain in the air of the room, the respirator is taken off outside the room after the door is closed, followed by hand hygiene. Gloves, eyewear and gown are removed first.
Answer
D · After leaving the room and closing the door
4.Infection control & patient safety
Answer: D · Helping the patient bathe while wearing a gown and gloves
Why this is the answer
Assistive personnel can carry out routine care for a stable patient, using the correct PPE. Assessment, teaching and clinical judgement, such as deciding when to stop precautions, cannot be delegated to them.
Answer
D · Helping the patient bathe while wearing a gown and gloves
5.Prioritization & delegation
Answer: C · “I will swallow the tablet with a glass of water.”
Why this is the answer
Sublingual tablets dissolve under the tongue and are absorbed quickly there. Sitting down reduces falls from low blood pressure, the tablets are protected from light and moisture, and headache is a common side effect.
Answer
C · “I will swallow the tablet with a glass of water.”
6.Prioritization & delegation
Answer: C · Decline, explain why and suggest who can safely do it
Why this is the answer
Nurses must work within their legal scope of practice, even when asked by a provider. The nurse declines, explains the reason and helps find a suitable professional.
Answer
C · Decline, explain why and suggest who can safely do it
7.Clinical nursing
Answer: D · Pain out of proportion to the injury, especially on passive stretch
Why this is the answer
Increasing pain that is not relieved by analgesia and worsens with passive stretching is the earliest sign. Pallor, numbness and absent pulses are late signs.
Answer
D · Pain out of proportion to the injury, especially on passive stretch
8.Clinical nursing
Answer: C · Give another dose of fast-acting carbohydrate and recheck
Why this is the answer
If blood glucose remains below the threshold (4 mmol/L in UK guidance, 70 mg/dL in US guidance), the fast-acting treatment is repeated. Once it is above the threshold, a longer-acting carbohydrate such as a sandwich or the next meal helps prevent recurrence.
Answer
C · Give another dose of fast-acting carbohydrate and recheck
9.Lab values & electrolytes
Answer: D · About 7–14 days after treatment
Why this is the answer
Chemotherapy damages dividing marrow cells, but mature neutrophils and platelets already in the blood survive for a while, so counts usually fall to a nadir about 7–14 days later, depending on the drug. Infection and bleeding risks are highest then.
Answer
D · About 7–14 days after treatment
10.Lab values & electrolytes
Answer: A · Primary hyperaldosteronism
Why this is the answer
Excess aldosterone causes sodium and water retention (hypertension), potassium loss (hypokalemia) and hydrogen ion loss (metabolic alkalosis). Adrenal insufficiency causes the opposite pattern, with low sodium and high potassium.Checked against:Primary and secondary hyperaldosteronism · MedlinePlus (NIH) (2025); Alkalosis · StatPearls (NCBI Bookshelf) (2024)
Answer
A · Primary hyperaldosteronism
11.Pharmacology
Answer: C · Extrapyramidal movement disorders such as acute dystonia
Why this is the answer
Metoclopramide is a dopamine D2 antagonist. Blocking dopamine in the basal ganglia can cause dystonia and other extrapyramidal effects, more often in young adults.
Answer
C · Extrapyramidal movement disorders such as acute dystonia
12.Pharmacology
Answer: D · GFR depends on angiotensin II constricting the efferent arteriole
Why this is the answer
When renal perfusion is low, angiotensin II constricts the efferent arteriole to maintain glomerular pressure. Blocking it lets the pressure and GFR fall, so kidney function can drop sharply.
Answer
D · GFR depends on angiotensin II constricting the efferent arteriole
13.Med-surg: cardiovascular & respiratory
Answer: A · Statins reduce further events whatever the starting cholesterol
Why this is the answer
After ACS, high-intensity statin therapy reduces recurrent MI, stroke and death regardless of baseline cholesterol, partly by stabilising plaques. It is part of standard secondary prevention with antiplatelets, beta-blockers, ACE inhibitors and lifestyle change.
Answer
A · Statins reduce further events whatever the starting cholesterol
14.Med-surg: cardiovascular & respiratory
Answer: B · "I will use a salt substitute instead of ordinary salt."
Why this is the answer
Many salt substitutes contain potassium chloride. With an ACE inhibitor and spironolactone, both of which raise potassium, they can cause dangerous hyperkalaemia. Daily weights, reporting rapid weight gain and avoiding NSAIDs (which cause fluid retention) are correct.
Answer
B · "I will use a salt substitute instead of ordinary salt."
15.Med-surg: neuro, endocrine & renal
Answer: D · 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
D · They break the drugs down slowly and are more sensitive to them
16.Med-surg: neuro, endocrine & renal
Answer: B · "If she is unconscious, I will pour juice into her mouth."
Why this is the answer
An unconscious person cannot swallow safely, so fluids in the mouth can be aspirated. The family should put the person in the recovery position, give glucagon if trained and call for help. Once awake and able to swallow, the person eats a longer-acting carbohydrate.
Answer
B · "If she is unconscious, I will pour juice into her mouth."
17.Med-surg: GI, perioperative & oncology
Answer: B · Withdrawal occurs if the drug is stopped suddenly
Why this is the answer
Physical dependence is a predictable adaptation to regular opioids, causing withdrawal if they stop suddenly, so doses are tapered. Addiction is a behavioural condition with craving, loss of control and continued use despite harm.
Answer
B · Withdrawal occurs if the drug is stopped suddenly
18.Med-surg: GI, perioperative & oncology
Answer: C · Use the spill kit with PPE, clean up, bag as cytotoxic waste and report
Why this is the answer
Cytotoxic spills are managed using a dedicated spill kit with gloves, gown, eye protection and a mask as needed. The spill is contained, absorbed and cleaned from the outside in, waste is placed in labelled cytotoxic waste and the incident is reported.
Answer
C · Use the spill kit with PPE, clean up, bag as cytotoxic waste and report
19.Maternity & obstetric nursing
Answer: C · A single palmar crease and low tone
Why this is the answer
Features of Down syndrome include hypotonia, upslanting palpebral fissures, a flat nasal bridge, a single palmar crease and a gap between the first and second toes. Heart defects are common, so an echocardiogram is arranged.
Answer
C · A single palmar crease and low tone
20.Maternity & obstetric nursing
Answer: C · The baby has a higher risk of early sepsis
Why this is the answer
Maternal fever, prolonged rupture of membranes and intra-amniotic infection are risk factors for early-onset sepsis. Many protocols require observation of vital signs and feeding, and sometimes blood tests or antibiotics.
Answer
C · The baby has a higher risk of early sepsis
21.Pediatric nursing
Answer: B · Preventing dehydration
Why this is the answer
Hand, foot and mouth disease, usually caused by coxsackievirus, is self-limiting. The main risk is dehydration from painful mouth ulcers, so cool fluids, soft foods and analgesia are given and wet nappies are monitored.
Answer
B · Preventing dehydration
22.Pediatric nursing
Answer: B · 500 g, about 5% of his body weight, mostly fluid
Why this is the answer
10 kg − 9.5 kg = 0.5 kg; 0.5 ÷ 10 = 5%. Rapid weight loss during acute illness is mostly fluid, so it is a useful measure of the degree of dehydration, alongside clinical signs.
Answer
B · 500 g, about 5% of his body weight, mostly fluid
23.Mental health nursing
Answer: B · Its anticholinergic effects can cause confusion, urine retention and falls
Why this is the answer
Diphenhydramine is strongly anticholinergic and sedating. In older adults, it can cause delirium, constipation, urinary retention and falls, and is generally avoided.
Answer
B · Its anticholinergic effects can cause confusion, urine retention and falls
24.Mental health nursing
Answer: D · Recognise that anxiety spreads between people, and calm herself first
Why this is the answer
Anxiety can be communicated between people. A nurse who notices and manages her own anxiety can provide a calm, steady presence that helps reduce the patient's anxiety.
Answer
D · Recognise that anxiety spreads between people, and calm herself first
25.Nursing math & unit conversions
Answer: x = 67.1 kg
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 tenths place
67.1247 → 1
Only the next digit decides
67.1247 → 2
2 is 4 or less, so 1 stays.
The digits after it (47) are ignored: round once, never step by step.
Round
x = 67.1 kg
Answer
x = 67.1 kg
26.Nursing math & unit conversions
Answer: V = 0.48 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.
Volume in a day
20 mL/h × 24 h = 480 mL
In litres
V = 480/1000 = 0.48 L
Answer
V = 0.48 L
27.Dosage calculations
Answer: V = 4 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.
Dose from body weight
D = 4·20 = 80 mg
Volume
V = 80/20 = 4 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4 mL
28.Dosage calculations
Answer: V = 0.18 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 = 180/1000 = 0.18 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.18 mL
29.IV infusion rates
Answer: R = 50 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
5·60 = 300 min
Drip rate
R = 1500·10/300 = 50 gtt/min
Answer
R = 50 gtt/min
30.IV infusion rates
Answer: D = 20 mcg/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
50000 mcg/500 mL = 100 mcg/mL
Dose per hour
12·100 = 1200 mcg/h
Dose per minute
D = 1200/60 = 20 mcg/min
Answer
D = 20 mcg/min
31.Pediatric & critical-care dosing
Answer: D = 3 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
100/100 = 1 units/mL
Units per hour
D = 3·1 = 3 units/h
Answer
D = 3 units/h
32.Pediatric & critical-care dosing
Answer: R = 13.4 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
4·89 = 356 mcg/min
356·60 = 21360 mcg/h
Pump rate
R = 21360/1600 = 13.35 ≈ 13.4 mL/h
Answer
R = 13.4 mL/h
33.IV fluids & fluid balance
Answer: B = 290 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: 240 + 200 = 440 mL
ice chips: 200/2 = 100 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 2·50 = 100 mL
total intake = 1360 mL
Total output
375 + 225 + 300 + 70 + 100 = 1070 mL
Balance
B = 1360 − 1070 = 290 mL
Answer
B = 290 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 820 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
09:00 → 10:30 = 1.5 h
Volume infused
120·1.5 = 180 mL
Volume left
V = 1000 − 180 = 820 mL
Answer
V = 820 mL
35.Clinical assessment scores
Answer: B = 13
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: no impairment → 4
moisture: very moist → 2
activity: chairfast → 2
mobility: completely immobile → 1
nutrition: very poor → 1
friction and shear: no apparent problem → 3
Add
Braden total = 4 + 2 + 2 + 1 + 1 + 3 = 13
Answer
B = 13
36.Clinical assessment scores
Answer: low
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 16/min → 0
SpO₂ 99% → 0
on air → 0
SBP 96 mmHg → 2
HR 82/min → 0
alert (A) → 0
T 38.1 °C → 1
Total and red scores
NEWS2 = 0 + 0 + 0 + 2 + 0 + 0 + 1 = 3
No parameter scores 3.
Risk group
low
Answer
low
37.Arterial blood gas interpretation
Answer: PaCO₂ = 20 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 = 1.5·8 + 8 = 20 mmHg
range: 18–22 mmHg
Answer
PaCO₂ = 20 mmHg
38.Arterial blood gas interpretation
Answer: added metabolic alkalosis
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 = 144 − (93 + 13) = 38
Delta ratio
(38 − 12)/(24 − 13) = 2.364
added metabolic alkalosis
Answer
added metabolic alkalosis
39.ECG rhythm strip interpretation
Answer: atrial flutter, 4:1 conduction
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 = 20 small boxes, 1500 ÷ 20 ≈ 75 per minute.
2. Rhythm: regular, every R–R is 0.80 s.
3. P waves: none; regular sawtooth flutter waves every 0.20 s (300 per minute), 4 for each QRS.
4. PR interval: not measurable.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
atrial flutter, 4:1 conduction
Answer
atrial flutter, 4:1 conduction
40.ECG rhythm strip interpretation
Answer: ventricular rate = 29 bpm
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Atrial rate
P–P = 21 small boxes = 0.84 s → 1500 ÷ 21 = 71.43 ≈ 71 per minute
Ventricular rate
R–R = 51 small boxes = 2.04 s → 1500 ÷ 51 = 29.41 ≈ 29 per minute
Answer
ventricular rate = 29 bpm
Answer
ventricular rate = 29 bpm
Third-degree block with a wide-complex ventricular escape (usually 20–40 per minute).
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