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 small blood spill is found on the ward floor. What is the correct approach?
AWipe it up with a paper towel without gloves, then wash your hands well afterwards
BCover it with a sheet so no one steps in it
CLeave it for the domestic staff to clean at the end of the day
DWear gloves and an apron and clean it with an approved disinfectant per policy
2.Nursing fundamentalsHard
A patient receiving chemotherapy develops a temperature of 38.3 °C. Why is this treated as an emergency?
AChemotherapy always causes a fever that needs no action
BA fever shows the cancer has spread
CThey may have neutropenic sepsis, which can quickly become fatal
DThe fever means the chemotherapy has stopped working on the cancer
3.Infection control & patient safetyMedium
How are neuromuscular blocking drugs, such as vecuronium, safely stored?
ANext to common IV antibiotics so they are easy to find
BMixed in the same bin as other high-use drugs
CSeparate from other drugs, with a warning that they cause paralysis
DIn the general stock cupboard with the other IV drugs and no special labels
4.Infection control & patient safetyHard
Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?
ASlow the infusion rate
BRecord the new allergy in the chart
CStop the infusion
DGive an oral antihistamine
5.Prioritization & delegationMedium
Before giving a medication to a child, which check is especially important?
AThat the parent agrees with the time it is given
BThat the dose is correct for the child’s weight
CThat the child likes the taste of the drug
DThat the medicine cup is the child’s favorite color
6.Prioritization & delegationHard
An older adult with type 2 diabetes is confused and very dehydrated. The glucose is 900 mg/dL (50 mmol/L), and blood and urine show no significant ketones. What is the most likely problem?
AHyperosmolar hyperglycemic state
BStress-induced mild hyperglycemia
CDiabetic ketoacidosis
DHypoglycemia with rebound
7.Clinical nursingMedium
Why must a patient with a new coronary stent not stop their antiplatelet medicines without specialist advice?
AStopping early greatly increases the risk of a clot forming in the stent
BThe stent will dissolve if the drugs are stopped before the course ends
CStopping causes severe low blood pressure
DStopping causes immediate kidney failure
8.Clinical nursingHard
A patient with lung cancer develops swelling of the face and arms, distended neck veins and breathlessness that is worse lying down. What should be suspected?
ARight-sided heart failure from valve disease
BHypothyroidism
CSuperior vena cava obstruction
DAn allergic reaction to food
9.Lab values & electrolytesMedium
A patient scheduled for surgery this morning has a potassium of 3.0 mEq/L on pre-operative tests. What should the nurse do?
ASend the patient to surgery without comment
BReport it to the surgical team before surgery
CRepeat the test after the surgery is finished
DGive an oral potassium dose without a prescription
10.Lab values & electrolytesHard
A patient without symptoms has a TSH of 7.5 mIU/L on two occasions with a normal free T4. Which term fits best?
ASecondary hypothyroidism
BSubclinical hypothyroidism
CSubclinical hyperthyroidism
DOvert primary hypothyroidism
11.PharmacologyMedium
A patient wants to stop paroxetine suddenly. What should the nurse explain?
AIt can be stopped at any time, as antidepressants cause no withdrawal effects
CStopping suddenly causes the drug to work better for a while
DIt can cause dizziness, "electric shock" feelings and irritability
12.PharmacologyHard
Why is pyridoxine (vitamin B6) often given together with isoniazid for tuberculosis?
ATo increase the absorption of isoniazid
BTo reduce bacterial resistance
CTo prevent liver damage from isoniazid
DTo prevent peripheral neuropathy
13.Med-surg: cardiovascular & respiratoryMedium
How does intermittent pneumatic compression help prevent DVT?
AIt keeps the legs completely still to protect the veins
BIt breaks up and dissolves clots that have already formed in the veins
CIt warms the legs gently so the blood becomes thinner and flows faster
DIt squeezes the legs in cycles to push venous blood towards the heart
14.Med-surg: cardiovascular & respiratoryHard
A patient with a valid, documented do-not-attempt-CPR decision (DNACPR in the UK, DNR or DNAR in the US) is found in cardiac arrest. What should the nurse do?
ACall the arrest team and let them decide whether to resuscitate
BNot start CPR, call for support, and provide dignity and comfort
CStart CPR but use only chest compressions
DStart full CPR because the patient's family is not present
15.Med-surg: neuro, endocrine & renalMedium
A patient has a homonymous hemianopia after a stroke. How should the nurse help at first?
AApproach from the seeing side and teach head-turning to scan
BPut the call bell and drinks on the side without vision, to train it
CCover the eye on the affected side with a patch
DKeep the room dark to reduce visual stimulation
16.Med-surg: neuro, endocrine & renalHard
The nurse has four patients with diabetes. Which one needs to be seen first?
AA patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
BA newly diagnosed patient asking about which foods to eat
CA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating
DA patient waiting for a routine HbA1c test
17.Med-surg: GI, perioperative & oncologyMedium
Which finding suggests a deep tissue pressure injury?
AIntact skin that is purple or maroon over a bony area
BDry, flaky skin on both shins
CA small scratch on the skin with a little fresh red blood
DPale pink skin that blanches quickly when pressed
18.Med-surg: GI, perioperative & oncologyHard
During a nasogastric feed, a patient starts coughing and SpO₂ falls from 96% to 89%. What should the nurse do first?
AStop the feed and assess the airway and breathing
BLay the patient flat to help them rest
CIncrease the feed rate to finish it sooner
DGive a drink of water to clear the throat
19.Maternity & obstetric nursingMedium
A newborn at 42 weeks has dry, cracked, peeling skin, long nails and little vernix. How is this baby best described?
ALarge for gestational age
BPost-term (postmature)
CSmall for gestational age only
DPreterm
20.Maternity & obstetric nursingHard
A woman at 12 weeks has light bleeding and mild cramping. The cervix is closed and fetal heart activity is seen on ultrasound. How is this classified?
AThreatened miscarriage
BIncomplete miscarriage
CMissed miscarriage
DInevitable miscarriage
21.Pediatric nursingMedium
A child with a known peanut allergy is starting school. What is the most important step?
AAsking the child to tell the teachers if she feels unwell
BKeeping the auto-injector at home, so that it cannot be lost or misused by other children
CAllowing the child to eat only foods brought by classmates
DA written allergy action plan, with in-date auto-injectors and trained staff
22.Pediatric nursingHard
A child has suspected septic shock. Which action is the most time-critical?
AWaiting for the blood culture results before starting any antibiotic treatment
BGiving oral antibiotics and reviewing the child again in the morning
CGiving IV antibiotics as soon as possible, ideally within the first hour
DStarting antibiotics after the fever has been present for 24 hours
23.Mental health nursingMedium
Which side effects should the nurse monitor for in a patient starting donepezil?
ADry mouth, constipation and urinary retention
BTremor, thirst and passing large amounts of urine
CNausea, diarrhoea and a slow heart rate
DWeight gain and high blood glucose
24.Mental health nursingHard
A 50-year-old man has believed for a year that his wife is unfaithful. He works normally, his speech is organised and he has no hallucinations. Which diagnosis is most likely?
ABipolar I disorder
BDelusional disorder
CSchizophrenia
DSchizophreniform disorder
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 6 lb 13 oz. Using 1 lb = 16 oz and 1 kg = 2.2 lb, find the weight m in kilograms. Round to two decimal places.
6 lb 13 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A serum creatinine result is 1.5 mg/dL. Using 1 mg/dL = 88.4 µmol/L for creatinine, find c in µmol/L to the nearest whole number.
1.5 mg/dL1 mg/dL = 88.4 µmol/L
c = µmol/L
27.Dosage calculationsMedium
A patient weighs 15 kg and is prescribed 7.5 mg/kg as a single dose. Find the dose D in mg.
15 kg7.5 mg/kg
D = mg
28.Dosage calculationsHard
A patient is 136 cm tall and weighs 54 kg. The prescription is 250 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
136 cm54 kg250 mg/m²
D = mg
29.IV infusion ratesMedium
500 mL was ordered over 6 hours. After 4 hours you find that 210 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
500 mL / 6 hafter 4 h: 210 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 100 mg of a drug in 250 mL and runs at 12 mL/h. How many milligrams per hour D does the patient receive?
100 mg/250 mL12 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 80 units/kg for a patient who weighs 104 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg104 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 7.5 mcg/kg/min for a patient who weighs 105 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL7.5 mcg/kg/min105 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL infusion starts at 17:00 at 150 mL/h. After 4 hours the rate is changed to 200 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL150 mL/h · 4 h200 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: slightly limited; moisture: occasionally moist; activity: chairfast; mobility: slightly limited; nutrition: excellent; 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). An adult weighs 87 kg and is 198 cm tall. Calculate the BMI and click the WHO weight category.
87 kg198 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 7.52, PaCO₂ 49 mmHg (6.5 kPa) and HCO₃⁻ 39 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.52PaCO₂ 49 mmHg (6.5 kPa)HCO₃⁻ 39 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a respiratory acidosis: pH 7.30, PaCO₂ 78 mmHg (10.4 kPa), HCO₃⁻ 37 mmol/L. Use the rules ‘HCO₃⁻ rises 1 mmol/L per 10 mmHg (acute) or 3.5 mmol/L per 10 mmHg (chronic)’ to classify it. Click your answer.
pH 7.30PaCO₂ 78 mmHg (10.4 kPa)HCO₃⁻ 37 mmol/L
1acute
2chronic
3acute on chronic
39.ECG rhythm strip interpretationMedium
This lead II strip shows atrial flutter with a fixed conduction ratio. Find the ventricular rate in beats per minute.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ventricular rate = bpm
40.ECG rhythm strip interpretationHard
This 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: D · Wear gloves and an apron and clean it with an approved disinfectant per policy
Why this is the answer
Under standard precautions all blood is handled as potentially infectious. Spills are cleaned promptly using PPE and the spill kit or disinfectant set out in local policy.
Answer
D · Wear gloves and an apron and clean it with an approved disinfectant per policy
2.Nursing fundamentals
Answer: C · They may have neutropenic sepsis, which can quickly become fatal
Why this is the answer
Patients with a low neutrophil count may have few signs of infection apart from fever and can deteriorate fast. Urgent assessment and IV antibiotics, usually within an hour, are needed.
Answer
C · They may have neutropenic sepsis, which can quickly become fatal
3.Infection control & patient safety
Answer: C · Separate from other drugs, with a warning that they cause paralysis
Why this is the answer
Neuromuscular blockers stop breathing. They are stored apart from other drugs, often in sealed or colored containers with warnings such as “Paralyzing agent: causes respiratory arrest”.
Answer
C · Separate from other drugs, with a warning that they cause paralysis
4.Infection control & patient safety
Answer: C · Stop the infusion
Why this is the answer
These are signs of anaphylaxis. The nurse stops the infusion at once, calls for help and supports the airway, and intramuscular epinephrine (adrenaline) is the first-line treatment. Documentation comes later.
Answer
C · Stop the infusion
5.Prioritization & delegation
Answer: B · That the dose is correct for the child’s weight
Why this is the answer
Pediatric doses are usually calculated by weight, and errors can cause serious harm. The nurse checks the dose against the child’s weight and the safe range before giving it.
Answer
B · That the dose is correct for the child’s weight
6.Prioritization & delegation
Answer: A · Hyperosmolar hyperglycemic state
Why this is the answer
Hyperosmolar hyperglycemic state occurs mainly in type 2 diabetes, with extreme glucose, severe dehydration and little or no ketosis. Treatment starts with IV fluids, as in DKA.
Answer
A · Hyperosmolar hyperglycemic state
7.Clinical nursing
Answer: A · Stopping early greatly increases the risk of a clot forming in the stent
Why this is the answer
Dual antiplatelet therapy prevents stent thrombosis while the stent becomes covered by the artery lining. Stopping early can cause a sudden myocardial infarction.
Answer
A · Stopping early greatly increases the risk of a clot forming in the stent
8.Clinical nursing
Answer: C · Superior vena cava obstruction
Why this is the answer
Superior vena cava obstruction prevents venous drainage from the head and arms. It is an oncological emergency; patients are positioned upright and need urgent specialist treatment.
Answer
C · Superior vena cava obstruction
9.Lab values & electrolytes
Answer: B · Report it to the surgical team before surgery
Why this is the answer
Hypokalemia increases the risk of arrhythmias during anesthesia and can prolong muscle weakness. Abnormal pre-operative results are reported to the surgeon and anesthetist, who decide whether to correct it or delay surgery.Checked against:Hypokalemia · StatPearls (NCBI Bookshelf) (2025)
Answer
B · Report it to the surgical team before surgery
10.Lab values & electrolytes
Answer: B · Subclinical hypothyroidism
Why this is the answer
A raised TSH with a normal free T4 is subclinical hypothyroidism; the pituitary is working harder to keep T4 normal. Overt hypothyroidism has a low free T4, and subclinical hyperthyroidism has a low TSH.Checked against:TSH (Thyroid-stimulating hormone) Test · MedlinePlus (NIH) (2024)
Answer
B · Subclinical hypothyroidism
11.Pharmacology
Answer: D · It can cause dizziness, "electric shock" feelings and irritability
Why this is the answer
Antidepressant discontinuation syndrome is common with short half-life drugs such as paroxetine and venlafaxine. The dose is tapered gradually under supervision.
Answer
D · It can cause dizziness, "electric shock" feelings and irritability
12.Pharmacology
Answer: D · To prevent peripheral neuropathy
Why this is the answer
Isoniazid causes pyridoxine deficiency, which can lead to peripheral neuropathy. The risk is greater in slow acetylators, malnourished patients and people with diabetes or alcohol dependence.
Answer
D · To prevent peripheral neuropathy
13.Med-surg: cardiovascular & respiratory
Answer: D · It squeezes the legs in cycles to push venous blood towards the heart
Why this is the answer
Inflatable sleeves around the calves or feet inflate and deflate in cycles, increasing venous return and reducing stasis. They are used when anticoagulation is unsuitable or alongside it. They are not used on a leg with a known DVT or severe arterial disease.
Answer
D · It squeezes the legs in cycles to push venous blood towards the heart
14.Med-surg: cardiovascular & respiratory
Answer: B · Not start CPR, call for support, and provide dignity and comfort
Why this is the answer
A valid do-not-attempt-CPR decision means CPR is not attempted. Other appropriate care continues, the senior team and family are informed and the patient is cared for with dignity. Nurses should check that the decision is valid and applies to the situation.
Answer
B · Not start CPR, call for support, and provide dignity and comfort
15.Med-surg: neuro, endocrine & renal
Answer: A · Approach from the seeing side and teach head-turning to scan
Why this is the answer
Initially, placing important items and approaching from the side with intact vision improves safety. Over time the patient is taught to scan by turning the head towards the lost field. Patching one eye does not help, because both eyes have lost the same half-field.
Answer
A · Approach from the seeing side and teach head-turning to scan
16.Med-surg: neuro, endocrine & renal
Answer: A · A patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
Why this is the answer
Hypoglycaemia with confusion can rapidly lead to seizures and loss of consciousness, so it is treated at once. A moderately high glucose without symptoms, diet questions and routine tests can wait.
Answer
A · A patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
17.Med-surg: GI, perioperative & oncology
Answer: A · Intact skin that is purple or maroon over a bony area
Why this is the answer
A deep tissue injury appears as persistent purple, maroon or dark discolouration, or a blood-filled blister, from pressure and shear on underlying tissue. It may quickly turn into a deep wound.
Answer
A · Intact skin that is purple or maroon over a bony area
18.Med-surg: GI, perioperative & oncology
Answer: A · Stop the feed and assess the airway and breathing
Why this is the answer
Coughing and desaturation suggest aspiration or a displaced tube. The feed is stopped, the patient is sat up, oxygen is given as needed, and medical review and checking of tube position follow.
Answer
A · Stop the feed and assess the airway and breathing
19.Maternity & obstetric nursing
Answer: B · Post-term (postmature)
Why this is the answer
Post-term babies often have dry, peeling skin, long nails, little vernix and lanugo and an alert look. They may also have meconium staining and are at risk of hypoglycaemia.
Answer
B · Post-term (postmature)
20.Maternity & obstetric nursing
Answer: A · Threatened miscarriage
Why this is the answer
Bleeding with a closed cervix and a viable pregnancy is a threatened miscarriage; many continue normally. An open cervix means an inevitable or incomplete miscarriage, and a missed miscarriage has no fetal heart activity.
Answer
A · Threatened miscarriage
21.Pediatric nursing
Answer: D · A written allergy action plan, with in-date auto-injectors and trained staff
Why this is the answer
Schools need an individual action plan describing symptoms and steps, staff trained to recognise anaphylaxis and give adrenaline, and auto-injectors that are always quickly available. Avoiding the allergen and not sharing food also help.
Answer
D · A written allergy action plan, with in-date auto-injectors and trained staff
22.Pediatric nursing
Answer: C · Giving IV antibiotics as soon as possible, ideally within the first hour
Why this is the answer
In septic shock, IV antibiotics are given as soon as possible, ideally within an hour of recognition, after cultures are taken if this does not cause delay. Fluid resuscitation and close monitoring are started at the same time.
Answer
C · Giving IV antibiotics as soon as possible, ideally within the first hour
23.Mental health nursing
Answer: C · Nausea, diarrhoea and a slow heart rate
Why this is the answer
Cholinesterase inhibitors increase cholinergic activity. Common effects include nausea, vomiting, diarrhoea and loss of appetite; bradycardia and fainting can also occur.
Answer
C · Nausea, diarrhoea and a slow heart rate
24.Mental health nursing
Answer: B · Delusional disorder
Why this is the answer
Delusional disorder involves one or more delusions for at least 1 month, without other prominent symptoms of schizophrenia, and functioning is not markedly impaired apart from the effects of the delusion. Jealous delusions are one recognised type.
Answer
B · Delusional disorder
25.Nursing math & unit conversions
Answer: m = 3.1 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
13 oz/16 = 0.8125 lb
6 + 0.8125 = 6.813 lb
Pounds to kilograms
m = 6.813/2.2 = 3.097 ≈ 3.1 kg
Answer
m = 3.1 kg
26.Nursing math & unit conversions
Answer: c = 133 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 = 1.5·88.4 = 132.6 ≈ 133 µmol/L
Answer
c = 133 µmol/L
27.Dosage calculations
Answer: D = 112.5 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.
Dose
7.5·15 = 112.5 mg
Answer
D = 112.5 mg
28.Dosage calculations
Answer: D = 357.1 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 = √(136·54/3600) = √2.04 = 1.428 m²
Dose
D = 250·1.428 = 357.1 mg
Answer
D = 357.1 mg
29.IV infusion rates
Answer: R = 105 mL/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.
Original rate
500/6 = 83.33 mL/h
New rate
R = 210/2 = 105 mL/h
Answer
R = 105 mL/h
This is more than a 25% increase: most hospitals require you to contact the prescriber instead of catching up, and to assess the patient for fluid overload.
30.IV infusion rates
Answer: D = 4.8 mg/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.
Concentration
100/250 = 0.4 mg/mL
Dose rate
D = 0.4·12 = 4.8 mg/h
Answer
D = 4.8 mg/h
31.Pediatric & critical-care dosing
Answer: V = 8.3 mL
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 needed
80·104 = 8 320 units
Volume
V = 8320/1000 = 8.32 ≈ 8.3 mL
Answer
V = 8.3 mL
32.Pediatric & critical-care dosing
Answer: R = 47.3 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
250 mg = 250 000 mcg
250 000/250 = 1000 mcg/mL
Dose per minute and per hour
7.5·105 = 787.5 mcg/min
787.5·60 = 47250 mcg/h
Pump rate
R = 47250/1000 = 47.25 ≈ 47.3 mL/h
Answer
R = 47.3 mL/h
33.IV fluids & fluid balance
Answer: B = −150 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: 120 + 100 + 100 = 320 mL
ice chips: 100/2 = 50 mL
IV infusion: 60·8 = 480 mL
IV antibiotic: 2·50 = 100 mL
total intake = 950 mL
Total output
400 + 200 + 300 + 200 = 1100 mL
Balance
B = 950 − 1100 = −150 mL
Answer
B = −150 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: t = 6 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
150·4 = 600 mL
1000 − 600 = 400 mL left
Second part
400/200 = 2 h
Total time
t = 4 + 2 = 6 h
Answer
t = 6 h
That is about 6 h 00 min, so the bag runs out at about 23:00.
35.Clinical assessment scores
Answer: B = 18
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: slightly limited → 3
moisture: occasionally moist → 3
activity: chairfast → 2
mobility: slightly limited → 3
nutrition: excellent → 4
friction and shear: no apparent problem → 3
Add
Braden total = 3 + 3 + 2 + 3 + 4 + 3 = 18
Answer
B = 18
36.Clinical assessment scores
Answer: healthy weight
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 = 87/1.98² = 22.19
Category
healthy weight
Answer
healthy weight
37.Arterial blood gas interpretation
Answer: partially compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.52: alkalaemia (above 7.45)
PaCO₂ 49 mmHg: high (35–45)
HCO₃⁻ 39 mmol/L: high (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: chronic
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected HCO₃⁻
acute: 24 + 1·3.8 = 27.8 mmol/L
chronic: 24 + 3.5·3.8 = 37.3 mmol/L
Compare
measured: 37 mmol/L → chronic
Answer
chronic
39.ECG rhythm strip interpretation
Answer: ventricular rate = 150 bpm
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 10 small boxes = 0.40 s → 1500 ÷ 10 = 150 per minute
conduction ratio = 300 ÷ 150 = 2:1
Answer
ventricular rate = 150 bpm
40.ECG rhythm strip interpretation
Answer: ventricular rate = 56 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 = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 ≈ 75 per minute
Ventricular rate
R–R = 27 small boxes = 1.08 s → 1500 ÷ 27 = 55.56 ≈ 56 per minute
Answer
ventricular rate = 56 bpm
Answer
ventricular rate = 56 bpm
Third-degree block with a narrow-complex junctional escape (usually 40–60 per minute).
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