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 has just died. What should the nurse find out before starting last offices?
AThe patient's blood group
BThe family's religious and cultural wishes
CThe patient's favourite food
DWhether the patient's bills had all been paid
2.Nursing fundamentalsHard
Why must concentrated potassium chloride never be given as a quick intravenous injection?
AIt can cause a fatal cardiac arrest
BIt makes the vein turn blue for a week
CIt stops the kidneys from working at once
DIt makes the potassium inactive in the blood
3.Infection control & patient safetyMedium
Where should the dispersive (grounding) pad for electrosurgery be placed?
AOver a bony prominence such as the hip bone
BOver an area with scar tissue or a tattoo, so that the pad does not slip
COn skin that is wet with antiseptic prep
DOn clean, dry skin over a well-perfused muscle, close to the surgical site
4.Infection control & patient safetyHard
A patient has a rash, and both smallpox and chickenpox are considered. Which finding suggests smallpox?
ASmall crops of new lesions appearing over several days in a row
BA rash that is very itchy and starts on the trunk
CLesions all at the same stage, most dense on the face and limbs
DLesions at different stages, most dense on the trunk
5.Prioritization & delegationMedium
A patient is admitted with diabetic ketoacidosis. Which prescribed treatment is usually started first?
AIV isotonic fluid such as 0.9% sodium chloride
BSubcutaneous long-acting insulin only, given once
CA high-carbohydrate meal
DOral potassium tablets
6.Prioritization & delegationHard
After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?
ASeptic shock
BHypovolemic shock
CCardiac tamponade
DNeurogenic shock
7.Clinical nursingMedium
Before giving a beta-blocker, which observation is most important to check?
ATemperature only
BBowel movements
CHeart rate and blood pressure
DBlood glucose only
8.Clinical nursingHard
A nurse teaches a patient with heart failure about self-care. Which statement shows a need for further teaching?
A"I will weigh myself each morning after passing urine."
B"I only need to weigh myself once a month."
C"I will report it if I need more pillows to sleep."
D"I will take my water tablet in the morning."
9.Lab values & electrolytesMedium
A urine culture is ordered for a patient with an indwelling urinary catheter. How should the nurse collect the sample?
AAspirate from the sampling port with a sterile syringe
BDisconnect the catheter from the tubing and let it drain
CPour urine from the drainage bag into a sterile cup
DRemove the catheter and culture the catheter tip
10.Lab values & electrolytesHard
A patient with heart failure takes lisinopril, spironolactone and a potassium supplement. Today the potassium is 6.0 mEq/L. What is the most likely explanation?
APotassium supplements have no effect on the serum level
BSeveral medicines that raise potassium are being taken together
CLisinopril lowers potassium
DSpironolactone causes potassium loss
11.PharmacologyMedium
Which drug is the antidote for an opioid overdose?
AAtropine
BAcetylcysteine
CFlumazenil
DNaloxone
12.PharmacologyHard
Why is sildenafil contraindicated in a patient who uses nitrates for angina?
ANitrates block the metabolism of sildenafil in the liver
BBoth raise cGMP in vascular smooth muscle and can cause severe hypotension
CThe combination causes dangerous hyperkalaemia
DSildenafil blocks the conversion of nitrates into nitric oxide in the vessels
13.Med-surg: cardiovascular & respiratoryMedium
A patient is on a short course of oral prednisolone for an asthma exacerbation. Which effect should the nurse monitor for?
ALow blood sodium
BLow blood pressure
CRaised blood glucose
DSlow heart rate
14.Med-surg: cardiovascular & respiratoryHard
A 25-year-old non-smoker has wheeze and cough that come and go, worse at night and after exercise. Spirometry improves markedly after a bronchodilator. Which diagnosis is most likely?
AHeart failure
BIdiopathic pulmonary fibrosis
CAsthma
DCOPD
15.Med-surg: neuro, endocrine & renalMedium
A patient has acute glomerulonephritis with oedema and high blood pressure. Which nursing care is most appropriate?
ACheck the weight once a week
BEncourage a high-salt diet to balance the fluids
CMonitor BP, fluid balance and daily weight
DGive large amounts of IV fluid
16.Med-surg: neuro, endocrine & renalHard
A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?
AFood is absorbed slowly, so the insulin peaks before the glucose rises
BThe insulin has gone off and needs replacing
CThe patient is secretly eating sweets between meals
DThe meter gives false results for several hours after every meal
17.Med-surg: GI, perioperative & oncologyMedium
Which advice is appropriate for a patient with a very low platelet count?
AUse a soft toothbrush and an electric razor
BTake aspirin regularly for headaches
CFloss hard every day to prevent gum disease
DUse a razor blade for shaving every day
18.Med-surg: GI, perioperative & oncologyHard
A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?
AEncourage the patient to rest the voice and reassess tomorrow
BCall for urgent anaesthetic help, as the airway is swelling
CLay the patient flat to help them sleep
DGive a warm drink to soothe the throat
19.Maternity & obstetric nursingMedium
Progesterone relaxes smooth muscle in pregnancy. Which common complaint does this help explain?
AConstipation
BGum bleeding
CNasal stuffiness
DIncreased appetite
20.Maternity & obstetric nursingHard
A woman at 40 weeks calls the unit. Her contractions are every 10 to 20 minutes and irregular, her membranes are intact and the baby is moving well. What is the best advice?
ALie flat on her back and count the contractions for 4 hours
BTake a laxative to stimulate labour
CCome in immediately by ambulance
DRest at home and come in if contractions become regular
21.Pediatric nursingMedium
A 5-week-old baby has forceful (projectile) vomiting after every feed and seems hungry afterwards. What is the likely cause?
AHirschsprung disease
BGastro-oesophageal reflux that is normal for age
CPyloric stenosis
DIntussusception
22.Pediatric nursingHard
A 15-year-old in traction for a femur fracture is withdrawn and irritable. Which intervention best fits his developmental stage?
AAsk his parents to stay with him at all times and make decisions for him
BArrange contact with friends and let him control parts of his daily routine
CSet a strict timetable for him that staff decide without his input
DMove him to a room with toddlers so the ward is less lonely
23.Mental health nursingMedium
A patient with schizophrenia says, "The voices are telling me I'm evil." Which response is best?
A"I don't hear the voices, but I can see they are upsetting you. What are they saying to you?"
B"The voices aren't real, so just ignore them."
C"Let's not talk about the voices for now. Tell me about your family and your plans instead."
D"If you hear voices, you must be very ill."
24.Mental health nursingHard
A patient with anorexia nervosa is admitted with a BMI of 14, dizziness and low potassium. Which goal is the priority in the first days?
AGaining insight into family relationships through therapy
BImproving body image through group discussions
CMedical stabilisation, with careful refeeding and correction of electrolytes
DPlanning her return to university and her studies after discharge
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 8 lb 6 oz. Using 1 lb = 16 oz and 1 kg = 2.2 lb, find the weight m in kilograms. Round to two decimal places.
8 lb 6 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 1 tsp of an oral suspension every 6 hours for 7 days. The suspension comes in 100 mL bottles. Using 1 tsp = 5 mL, how many whole bottles N must be supplied so the course is complete?
1 tspevery 6 hours7 days100 mL1 tsp = 5 mL
N =
27.Dosage calculationsMedium
A patient weighs 80 kg. The prescribed dose is 10 mg/kg per day, given in 3 equal doses. How many milligrams D are given per dose?
80 kg10 mg/kg/day3× per day
D = mg
28.Dosage calculationsHard
The prescription is 7200 units of a drug that comes as 10000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
7200 units10000 units/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 30 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 2 hours?
30 gtt/min15 gtt/mL2 h
V = mL
30.IV infusion ratesHard
1500 mL was ordered over 10 hours. After 5 hours you find that 890 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1500 mL / 10 hafter 5 h: 890 mL
Δ = %
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 4 mL/h. How many units per hour D does the patient receive?
100 units/250 mL4 mL/h
D = units/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 500 mg in 250 mL. The order is 7.5 mcg/kg/min for a patient who weighs 103 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
500 mg/250 mL7.5 mcg/kg/min103 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The 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 bag was started at 06:30 and runs by pump at 120 mL/h. How many mL V are left in the bag at 08:30?
500 mL120 mL/h06:30 → 08:30
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: very limited; moisture: occasionally moist; activity: walks frequently; mobility: no limitation; nutrition: very poor; friction and shear: potential problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 53 kg and is 184 cm tall. Calculate the BMI and click the WHO weight category.
53 kg184 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.62, PaCO₂ 24 mmHg (3.2 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory alkalosis. How far is it compensated? Click your answer.
pH 7.62PaCO₂ 24 mmHg (3.2 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 43 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 43 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
This lead II strip shows sinus rhythm with one pause. Measure the pause, the R–R interval across it, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
pause = s
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1second-degree AV block type II
2dual-chamber (AV) paced rhythm
3idioventricular rhythm
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: B · The family's religious and cultural wishes
Why this is the answer
Some faiths have specific rules, for example about who may touch or wash the body and how soon burial should happen. Asking first respects the person and the family.
Answer
B · The family's religious and cultural wishes
2.Nursing fundamentals
Answer: A · It can cause a fatal cardiac arrest
Why this is the answer
A sudden rise in blood potassium can stop the heart. IV potassium is given diluted, by a controlled infusion and following strict policy, which is why concentrated forms are tightly controlled.
Answer
A · It can cause a fatal cardiac arrest
3.Infection control & patient safety
Answer: D · On clean, dry skin over a well-perfused muscle, close to the surgical site
Why this is the answer
The pad returns the current safely. Good contact over a well-perfused muscle prevents burns, while bony areas, scars, hair and moisture reduce contact and can cause burns at the pad site.
Answer
D · On clean, dry skin over a well-perfused muscle, close to the surgical site
4.Infection control & patient safety
Answer: C · Lesions all at the same stage, most dense on the face and limbs
Why this is the answer
In smallpox, lesions develop at the same stage in any one area and are densest on the face and extremities. In chickenpox, crops appear at different stages and are densest on the trunk.
Answer
C · Lesions all at the same stage, most dense on the face and limbs
5.Prioritization & delegation
Answer: A · IV isotonic fluid such as 0.9% sodium chloride
Why this is the answer
Patients with DKA are severely dehydrated, so IV isotonic fluid is started first. IV insulin follows, with close monitoring of potassium, which can fall quickly.
Answer
A · IV isotonic fluid such as 0.9% sodium chloride
6.Prioritization & delegation
Answer: D · Neurogenic shock
Why this is the answer
Neurogenic shock follows loss of sympathetic tone, causing vasodilation, hypotension and bradycardia with warm skin. Hypovolemic shock usually causes a fast pulse and cool, clammy skin.
Answer
D · Neurogenic shock
7.Clinical nursing
Answer: C · Heart rate and blood pressure
Why this is the answer
Beta-blockers lower heart rate and blood pressure, so bradycardia or hypotension may require withholding the dose and informing the prescriber.
Answer
C · Heart rate and blood pressure
8.Clinical nursing
Answer: B · "I only need to weigh myself once a month."
Why this is the answer
Daily weights at the same time with the same scales detect fluid retention early. A rapid gain, worsening breathlessness or needing more pillows should be reported.
Answer
B · "I only need to weigh myself once a month."
9.Lab values & electrolytes
Answer: A · Aspirate from the sampling port with a sterile syringe
Why this is the answer
The catheter sampling port is cleaned and urine is aspirated with a sterile syringe, keeping the system closed. Urine in the drainage bag has been standing and can contain bacteria that multiplied there; opening the system raises the risk of infection.
Answer
A · Aspirate from the sampling port with a sterile syringe
10.Lab values & electrolytes
Answer: B · Several medicines that raise potassium are being taken together
Why this is the answer
ACE inhibitors and spironolactone both make the kidneys retain potassium, and a supplement adds more. The nurse holds the supplement, informs the prescriber and checks kidney function and the ECG.Checked against:High potassium level · MedlinePlus (NIH) (2025); Spironolactone · MedlinePlus (NIH) (2018)
Answer
B · Several medicines that raise potassium are being taken together
11.Pharmacology
Answer: D · Naloxone
Why this is the answer
Naloxone reverses opioid-induced respiratory depression. Flumazenil reverses benzodiazepines, acetylcysteine treats paracetamol overdose and atropine treats bradycardia or organophosphate poisoning.
Answer
D · Naloxone
12.Pharmacology
Answer: B · Both raise cGMP in vascular smooth muscle and can cause severe hypotension
Why this is the answer
Nitrates increase cGMP production through nitric oxide and sildenafil blocks its breakdown by PDE5. Together they cause excessive vasodilation and a dangerous fall in blood pressure.
Answer
B · Both raise cGMP in vascular smooth muscle and can cause severe hypotension
13.Med-surg: cardiovascular & respiratory
Answer: C · Raised blood glucose
Why this is the answer
Corticosteroids raise blood glucose, which matters especially in diabetes. Short courses can also cause mood changes, insomnia, indigestion and fluid retention. Long-term use adds osteoporosis, adrenal suppression and infection risk.
Answer
C · Raised blood glucose
14.Med-surg: cardiovascular & respiratory
Answer: C · Asthma
Why this is the answer
Asthma typically causes variable symptoms with reversible airflow obstruction. COPD usually affects older people with a smoking history and causes persistent, poorly reversible obstruction. Fibrosis gives a restrictive pattern.
Answer
C · Asthma
15.Med-surg: neuro, endocrine & renal
Answer: C · Monitor BP, fluid balance and daily weight
Why this is the answer
In acute glomerulonephritis, salt and water retention cause oedema and hypertension. Close monitoring of BP, input and output and daily weights is needed, often with salt and fluid restriction and antihypertensives.
Answer
C · Monitor BP, fluid balance and daily weight
16.Med-surg: neuro, endocrine & renal
Answer: A · Food is absorbed slowly, so the insulin peaks before the glucose rises
Why this is the answer
Delayed gastric emptying means carbohydrate reaches the blood later than expected. The insulin acts too early, causing a hypo, and glucose rises later. The prescriber may change the timing, for example giving the insulin after the meal.
Answer
A · Food is absorbed slowly, so the insulin peaks before the glucose rises
17.Med-surg: GI, perioperative & oncology
Answer: A · Use a soft toothbrush and an electric razor
Why this is the answer
With thrombocytopenia, the nurse reduces bleeding risk: soft toothbrush, electric razor, no NSAIDs or aspirin, avoiding IM injections and rectal procedures, and reporting bleeding, bruising or blood in urine or stool.
Answer
A · Use a soft toothbrush and an electric razor
18.Med-surg: GI, perioperative & oncology
Answer: B · Call for urgent anaesthetic help, as the airway is swelling
Why this is the answer
Progressive hoarseness and stridor after a facial or inhalation burn mean the airway is narrowing. Early intubation by an experienced anaesthetist is needed before swelling makes it impossible. The patient is sat up and given oxygen.
Answer
B · Call for urgent anaesthetic help, as the airway is swelling
19.Maternity & obstetric nursing
Answer: A · Constipation
Why this is the answer
Progesterone slows gut motility, which causes constipation and contributes to heartburn because the lower oesophageal sphincter relaxes. Gum bleeding and nasal stuffiness are mainly due to oestrogen and increased blood flow.
Answer
A · Constipation
20.Maternity & obstetric nursing
Answer: D · Rest at home and come in if contractions become regular
Why this is the answer
Irregular, infrequent contractions with intact membranes and good movements suggest early or false labour. She can rest at home and should come in if contractions become regular and stronger, the membranes rupture, she bleeds or movements decrease.
Answer
D · Rest at home and come in if contractions become regular
21.Pediatric nursing
Answer: C · Pyloric stenosis
Why this is the answer
Pyloric stenosis typically presents at 2–8 weeks with projectile, non-bilious vomiting, hunger after vomiting, weight loss and sometimes a palpable olive-shaped mass.
Answer
C · Pyloric stenosis
22.Pediatric nursing
Answer: B · Arrange contact with friends and let him control parts of his daily routine
Why this is the answer
Adolescents are working on identity and independence, and peers are very important. Hospital stay threatens both, so contact with friends, privacy and choices about routines help him cope.
Answer
B · Arrange contact with friends and let him control parts of his daily routine
23.Mental health nursing
Answer: A · "I don't hear the voices, but I can see they are upsetting you. What are they saying to you?"
Why this is the answer
The nurse does not argue or agree, but states their own reality, shows empathy and asks about the content, especially command hallucinations that could put the patient or others at risk.
Answer
A · "I don't hear the voices, but I can see they are upsetting you. What are they saying to you?"
24.Mental health nursing
Answer: C · Medical stabilisation, with careful refeeding and correction of electrolytes
Why this is the answer
Severe malnutrition and electrolyte imbalance can be life-threatening. Medical stabilisation and safe refeeding come first; psychological therapy becomes more effective once she is physically safer.
Answer
C · Medical stabilisation, with careful refeeding and correction of electrolytes
25.Nursing math & unit conversions
Answer: m = 3.81 kg
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.
Ounces to pounds
6 oz/16 = 0.375 lb
8 + 0.375 = 8.375 lb
Pounds to kilograms
m = 8.375/2.2 = 3.807 ≈ 3.81 kg
Answer
m = 3.81 kg
26.Nursing math & unit conversions
Answer: N = 2
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.
Total volume
5 mL × 4 × 7 = 140 mL
Bottles
140/100 = 1.4 → N = 2
Answer
N = 2
27.Dosage calculations
Answer: D = 266.7 mg
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.
Total per day
10·80 = 800 mg
Per dose
D = 800/3 = 266.7 mg
Answer
D = 266.7 mg
28.Dosage calculations
Answer: V = 0.72 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 = 7200/10000 = 0.72 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.72 mL
29.IV infusion rates
Answer: V = 240 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
30·60/15 = 120 mL/h
Volume
V = 120·2 = 240 mL
Answer
V = 240 mL
30.IV infusion rates
Answer: Δ = 18.67 %
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
1500/10 = 150 mL/h
New rate
R = 890/5 = 178 mL/h
Percentage change
Δ = (178 − 150)/150·100% = 18.67%
Answer
Δ = 18.67%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: D = 1.6 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 = 4·0.4 = 1.6 units/h
Answer
D = 1.6 units/h
32.Pediatric & critical-care dosing
Answer: R = 23.2 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
500 mg = 500 000 mcg
500 000/250 = 2000 mcg/mL
Dose per minute and per hour
7.5·103 = 772.5 mcg/min
772.5·60 = 46350 mcg/h
Pump rate
R = 46350/2000 = 23.18 ≈ 23.2 mL/h
Answer
R = 23.2 mL/h
33.IV fluids & fluid balance
Answer: B = 320 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: 100 + 240 + 150 = 490 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1540 mL
Total output
375 + 450 + 325 + 70 = 1220 mL
Balance
B = 1540 − 1220 = 320 mL
Answer
B = 320 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 260 mL
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Elapsed time
06:30 → 08:30 = 2 h
Volume infused
120·2 = 240 mL
Volume left
V = 500 − 240 = 260 mL
Answer
V = 260 mL
35.Clinical assessment scores
Answer: B = 16
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: occasionally moist → 3
activity: walks frequently → 4
mobility: no limitation → 4
nutrition: very poor → 1
friction and shear: potential problem → 2
Add
Braden total = 2 + 3 + 4 + 4 + 1 + 2 = 16
Answer
B = 16
36.Clinical assessment scores
Answer: underweight
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 = 53/1.84² = 15.65
Category
underweight
Answer
underweight
37.Arterial blood gas interpretation
Answer: uncompensated
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 7.62: alkalaemia (above 7.45)
PaCO₂ 24 mmHg: low (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 51.1 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.
Expected PaCO₂
0.7·43 + 21 = 51.1 mmHg
Answer
PaCO₂ = 51.1 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: pause = 1.52 s
Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Measure
38 small boxes from R to R across the pause
Convert
pause = 38 × 0.04 s = 1.52 s
Compare with P–P
1.52 ÷ 0.92 ≈ 1.7 P–P cycles, not a whole number
Answer
pause = 1.52 s
No P wave appears in the pause, and the pause is not a whole number of P–P cycles: sinus arrest. A pause of exactly two or three cycles would point to sinus exit block.
40.ECG rhythm strip interpretation
Answer: paced rhythm, failure to capture
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: 5 QRS complexes in 6 s, × 10 = 50 per minute.
2. Rhythm: the pacing spikes are regular (every 0.96 s), but the R–R is not, because a QRS is missing after some spikes.
3. P waves: none visible.
4. PR interval: not measurable.
5. QRS: 0.16 s and wide after the captured spikes; one spike is not followed by a QRS (no capture).
Interpretation
paced rhythm, failure to capture
Answer
paced rhythm, failure to capture
Failure to capture: the pacemaker fires but the heart does not respond. Textbooks treat it as urgent to report, because the patient may depend on the pacemaker.
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