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
While wearing sterile gloves, where should the nurse keep their hands?
AFolded under the armpits to keep warm
BBehind the back when not in use
CResting on the edge of the sterile field
DAbove waist level and in sight
2.Nursing fundamentalsHard
Why must concentrated potassium chloride never be given as a quick intravenous injection?
AIt makes the vein turn blue for a week
BIt can cause a fatal cardiac arrest
CIt stops the kidneys from working at once
DIt makes the potassium inactive in the blood
3.Infection control & patient safetyMedium
When should a nurse call the rapid response team?
AOnly when the provider has written an order for a rapid response call in the chart
BOnly after a patient has had a cardiac or respiratory arrest on the ward
COnly when the patient’s family makes a complaint
DWhen a patient shows an acute decline, such as new confusion or a sharp change in vital signs
4.Infection control & patient safetyHard
During a procedure, a nurse sees that the team is about to start without a time-out. What should the nurse do?
AReport it to the manager at the end of the week
BSay nothing, because the surgeon is responsible for the procedure
CSpeak up clearly and stop the start until the time-out is done
DWait and raise the issue after the procedure is finished
5.Prioritization & delegationMedium
A nurse cannot read part of a medication order. What should the nurse do?
AAsk another nurse to guess what the order most likely says, then give it
BGive the usual dose of the drug the nurse thinks was meant
CSkip the drug and not tell anyone until the next ward round
DContact the prescriber to clarify the order before giving the drug
6.Prioritization & delegationHard
The charge nurse overhears four instructions from an RN to a nursing assistant. Which one needs to be corrected?
A“Walk him to the bathroom and back, and stay with him the whole time.”
B“Help him wash and change, and tell me at once if you see any red or broken skin.”
C“Check his glucose before lunch and tell me the number straight away.”
D“Check his glucose and give the insulin according to the sliding scale.”
7.Clinical nursingMedium
Which is a major risk factor for Clostridioides difficile infection?
ATaking regular paracetamol
BA diet high in fibre and fresh fruit
CRecent broad-spectrum antibiotic use
DRegular exercise
8.Clinical nursingHard
A drowsy patient in recovery is making snoring sounds and the SpO2 is falling. What is the first action?
AOpen the airway with a head tilt–chin lift or jaw thrust
BLie the patient face down
CGive sips of oral fluid to clear the throat and wake them
DWait for the patient to wake up fully
9.Lab values & electrolytesMedium
Which instruction is correct for a patient starting oral iron tablets?
AYour urine will turn bright orange while you take it
BTake the tablet with an antacid to improve absorption
CYour stools may turn dark green or black
DTake each tablet with milk to protect the stomach
10.Lab values & electrolytesHard
A patient has a hematocrit of 60% and a raised red cell mass. Which result suggests polycythemia vera rather than secondary polycythemia from chronic hypoxia?
AA high erythropoietin level
BA low oxygen saturation
CA low erythropoietin level
DA high carboxyhemoglobin
11.PharmacologyMedium
A patient takes isoniazid. Which advice is most important?
AExpect the urine to turn orange
BTake it with antacids to protect the stomach from irritation
CStop the drug when the cough improves
DAvoid alcohol and report jaundice, dark urine or poor appetite
12.PharmacologyHard
Why are antipsychotics used with great caution in older people with dementia?
AThey always cure the dementia and stop all behaviour problems
BThey are not absorbed in people over 65
CThey are linked to a higher risk of stroke and death
DThey cause severe hypoglycaemia in older people
13.Med-surg: cardiovascular & respiratoryMedium
According to current guidance, when should oxygen be given to a patient with an acute coronary syndrome?
ANever, because oxygen harms heart muscle
BAlways at 15 L/min, whatever the saturation
COnly when SpO₂ is below the target range
DOnly once the troponin result is available
14.Med-surg: cardiovascular & respiratoryHard
A patient who injects drugs has a fever, a new heart murmur and splinter haemorrhages. Before antibiotics are started, what is most important?
ATake a single blood culture from the cannula
BWait for an echocardiogram before taking any samples
CArrange an exercise ECG test
DTake several sets of blood cultures from separate sites
15.Med-surg: neuro, endocrine & renalMedium
Which measure best detects a decline in breathing in a patient with Guillain–Barré syndrome?
ADaily chest X-rays
BRegular forced vital capacity measurements
COxygen saturation alone
DPeak flow before and after a bronchodilator
16.Med-surg: neuro, endocrine & renalHard
After removal of a cortisol-producing adrenal adenoma, why may the patient need hydrocortisone for months?
AThe other adrenal gland has been suppressed
BThe operation always removes both adrenal glands
CThe tumour will grow back quickly without it
DHydrocortisone helps the wound to heal
17.Med-surg: GI, perioperative & oncologyMedium
How should a patient with facial burns usually be positioned?
ALying face down on the pillow to protect the airway
BLying flat with the head lower than the feet
CIn any position that keeps the face covered
DWith the head of the bed raised to reduce swelling
18.Med-surg: GI, perioperative & oncologyHard
During burn resuscitation, a 70 kg adult's urine output has been 120 mL/h for 3 hours, and the face and limbs are very oedematous. What should the nurse do?
AStop all IV fluids completely and remove the catheter
BIncrease the fluid rate to keep the output high
CDiscuss reducing the fluid rate with the team
DGive a diuretic without discussing it
19.Maternity & obstetric nursingMedium
Which finding is expected in a healthy breastfed newborn on day 3?
AA weight loss of about 15% of birth weight
BA weight loss of about 6% of birth weight
CA weight gain of 300 g since birth
DNo wet nappies in the last 24 hours
20.Maternity & obstetric nursingHard
Just after her membranes rupture in labour, a woman suddenly becomes very breathless, cyanosed and hypotensive. Which condition should be suspected?
AAmniotic fluid embolism
BSupine hypotension
CA panic attack
DNormal response to a strong contraction
21.Pediatric nursingMedium
A child with respiratory distress becomes bradycardic. What does this mean?
AA sign of severe hypoxia and possible imminent cardiac arrest
BThe child is recovering and calming down
CA normal response to sleep
DA side effect of the oxygen therapy
22.Pediatric nursingHard
An infant with a large VSD now breathes faster, sweats during feeds and has gained 300 g overnight with puffy eyelids. What does this most likely indicate?
ADehydration due to sweating during feeds
BWorsening heart failure with fluid retention
CAn allergic reaction to the new high-energy formula started yesterday
DGood growth thanks to improved feeding
23.Mental health nursingMedium
Which item is part of a safety plan for a person experiencing domestic violence?
ATelling the abuser about plans to leave so that he can prepare
BKeeping an emergency bag with documents, money and keys somewhere safe
CKeeping all important documents in the shared house
DAvoiding contact with friends and support services so as not to provoke him
24.Mental health nursingHard
On the third day of refeeding, a patient with severe anorexia nervosa develops swollen ankles, a low phosphate and an irregular pulse. What is most likely?
AAn allergic reaction to the food
BRefeeding syndrome
CNormal weight gain
DSerotonin syndrome
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.73223 mL. The rule in this exercise is that volumes below 1 mL are rounded to the nearest hundredth of a mL. What value x do you record?
0.73223 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 2 cups of tea, 2 fl oz of juice, 1½ tbsp of liquid supplement. Using the equivalents given, find the total oral intake V in mL.
1 cup = 8 fl oz = 240 mL1 fl oz = 30 mL1 tbsp = 15 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 25 kg. The prescribed dose is 20 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
25 kg20 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
The prescription is 860 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?
860 units1000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 500 mL over 10 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL10 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 200 mg of a drug in 500 mL and runs at 15 mL/h. How many milligrams per hour D does the patient receive?
200 mg/500 mL15 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 16 units/kg/h for a patient who weighs 100 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL16 units/kg/h100 kg
R = mL/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 90 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/min90 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 500 mL infusion starts at 18:00 at 75 mL/h. After 2 hours the rate is changed to 60 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL75 mL/h · 2 h60 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 20/min, SpO₂ 96% on room air, blood pressure 142/86 mmHg, pulse 98/min, alert, temperature 35.0 °C. What is the NEWS2 total score?
RR 20SpO₂ 96%airSBP 142HR 98AT 35.0 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). At 5 minutes after birth, a practice newborn has blue or pale skin all over, no heartbeat, no response to stimulation, limp limbs with no muscle tone and no breathing. Score the APGAR and click how the score is interpreted.
1reassuring
2moderately abnormal
3low
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 62 mmHg (8.3 kPa). Use the rule that in chronic respiratory acidosis HCO₃⁻ rises by 3.5 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a metabolic acidosis: pH 7.25, PaCO₂ 38 mmHg (5.1 kPa), HCO₃⁻ 16 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.25PaCO₂ 38 mmHg (5.1 kPa)HCO₃⁻ 16 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
39.ECG rhythm strip interpretationMedium
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Bazett’s formula QTc = QT/√RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
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
1idioventricular rhythm
2paced rhythm, failure to capture
3dual-chamber (AV) paced rhythm
4sinus rhythm with wide QRS
3Solutions
1.Nursing fundamentals
Answer: D · Above waist level and in sight
Why this is the answer
Sterile hands are kept in front of the body, above the waist and within sight, so accidental contamination is noticed. The edge of the field is not sterile.
Answer
D · Above waist level and in sight
2.Nursing fundamentals
Answer: B · 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
B · It can cause a fatal cardiac arrest
3.Infection control & patient safety
Answer: D · When a patient shows an acute decline, such as new confusion or a sharp change in vital signs
Why this is the answer
Rapid response teams bring critical care skills to a patient who is getting worse, with the aim of preventing cardiac arrest or ICU transfer. Any nurse who is worried about an acute change can call them.
Answer
D · When a patient shows an acute decline, such as new confusion or a sharp change in vital signs
4.Infection control & patient safety
Answer: C · Speak up clearly and stop the start until the time-out is done
Why this is the answer
The time-out is a key step to prevent wrong-patient, wrong-site and wrong-procedure errors. Any team member who sees it being skipped should speak up and halt the procedure until it is done.
Answer
C · Speak up clearly and stop the start until the time-out is done
5.Prioritization & delegation
Answer: D · Contact the prescriber to clarify the order before giving the drug
Why this is the answer
An unclear order must be clarified with the prescriber before the medication is given. Guessing or ignoring the order can harm the patient.
Answer
D · Contact the prescriber to clarify the order before giving the drug
6.Prioritization & delegation
Answer: D · “Check his glucose and give the insulin according to the sliding scale.”
Why this is the answer
Giving insulin is medication administration and needs a licensed nurse. Measuring glucose, hygiene and supervised walking are suitable tasks with clear reporting instructions.
Answer
D · “Check his glucose and give the insulin according to the sliding scale.”
7.Clinical nursing
Answer: C · Recent broad-spectrum antibiotic use
Why this is the answer
Broad-spectrum antibiotics disrupt normal gut flora, letting C. difficile overgrow. Older age, hospital stay and proton pump inhibitors also increase the risk.
Answer
C · Recent broad-spectrum antibiotic use
8.Clinical nursing
Answer: A · Open the airway with a head tilt–chin lift or jaw thrust
Why this is the answer
In a drowsy patient the tongue can fall back and obstruct the airway, causing snoring. Simple airway manoeuvres, oxygen and, if needed, an airway adjunct are used while help is called.
Answer
A · Open the airway with a head tilt–chin lift or jaw thrust
9.Lab values & electrolytes
Answer: C · Your stools may turn dark green or black
Why this is the answer
Oral iron commonly darkens the stools, which is harmless, but black tarry stools with abdominal pain should be reported. Milk, antacids and tea reduce absorption; vitamin C or orange juice can improve it.Checked against:Ferrograd C patient information leaflet (ferrous sulfate + vitamin C) · electronic medicines compendium (eMC), UK (2018)
Answer
C · Your stools may turn dark green or black
10.Lab values & electrolytes
Answer: C · A low erythropoietin level
Why this is the answer
In polycythemia vera, a marrow mutation (usually JAK2) drives red cell production, so erythropoietin is low. In secondary polycythemia from hypoxia (COPD, high altitude, smoking), erythropoietin is high. Often white cells and platelets are also raised in polycythemia vera.Checked against:Erythropoietin test · MedlinePlus (NIH) (2025); Polycythemia vera · MedlinePlus (NIH) (2025)
Answer
C · A low erythropoietin level
11.Pharmacology
Answer: D · Avoid alcohol and report jaundice, dark urine or poor appetite
Why this is the answer
Isoniazid can cause hepatitis, and alcohol increases the risk. Signs of liver injury are reported at once, and liver tests may be checked.
Answer
D · Avoid alcohol and report jaundice, dark urine or poor appetite
12.Pharmacology
Answer: C · They are linked to a higher risk of stroke and death
Why this is the answer
In older people with dementia, antipsychotics increase the risk of stroke and death. Non-drug approaches are tried first, and antipsychotics are used at low doses for short periods if needed.
Answer
C · They are linked to a higher risk of stroke and death
13.Med-surg: cardiovascular & respiratory
Answer: C · Only when SpO₂ is below the target range
Why this is the answer
Routine high-flow oxygen in patients who are not hypoxaemic offers no benefit and may increase infarct size. Oxygen is given when saturation falls below the target (for example below 90% in some guidelines, below 94% in others).
Answer
C · Only when SpO₂ is below the target range
14.Med-surg: cardiovascular & respiratory
Answer: D · Take several sets of blood cultures from separate sites
Why this is the answer
Suspected infective endocarditis requires multiple sets of blood cultures taken with careful aseptic technique, ideally before antibiotics, to identify the organism and guide weeks of IV therapy. Echocardiography looks for vegetations but should not delay cultures or, in a very sick patient, antibiotics.
Answer
D · Take several sets of blood cultures from separate sites
15.Med-surg: neuro, endocrine & renal
Answer: B · Regular forced vital capacity measurements
Why this is the answer
In Guillain–Barré syndrome, the breathing muscles weaken progressively. A falling vital capacity shows this early, long before oxygen saturation drops. A weak cough and difficulty counting in one breath are other warning signs.
Answer
B · Regular forced vital capacity measurements
16.Med-surg: neuro, endocrine & renal
Answer: A · The other adrenal gland has been suppressed
Why this is the answer
Excess cortisol from the adenoma suppressed ACTH, so the remaining adrenal gland is shrunken and underactive. Steroid replacement is needed until it recovers, which can take months. Stopping too early risks adrenal crisis.
Answer
A · The other adrenal gland has been suppressed
17.Med-surg: GI, perioperative & oncology
Answer: D · With the head of the bed raised to reduce swelling
Why this is the answer
Raising the head reduces facial and airway swelling. The airway is monitored closely because swelling can increase over the first 24–48 hours.
Answer
D · With the head of the bed raised to reduce swelling
18.Med-surg: GI, perioperative & oncology
Answer: C · Discuss reducing the fluid rate with the team
Why this is the answer
An output of about 1.7 mL/kg/h suggests over-resuscitation. Excess fluid ("fluid creep") worsens oedema and can cause pulmonary oedema and compartment syndromes, so the rate is reviewed and reduced under the burn protocol.
Answer
C · Discuss reducing the fluid rate with the team
19.Maternity & obstetric nursing
Answer: B · A weight loss of about 6% of birth weight
Why this is the answer
A loss of up to about 7–10% of birth weight is common in the first days, with birth weight usually regained by about 10–14 days. A larger loss or too few wet nappies needs a feeding assessment.
Answer
B · A weight loss of about 6% of birth weight
20.Maternity & obstetric nursing
Answer: A · Amniotic fluid embolism
Why this is the answer
Amniotic fluid embolism causes sudden breathlessness, hypoxia, hypotension and often bleeding from coagulopathy. It is an emergency: call the emergency team and start resuscitation as needed.
Answer
A · Amniotic fluid embolism
21.Pediatric nursing
Answer: A · A sign of severe hypoxia and possible imminent cardiac arrest
Why this is the answer
In children, bradycardia caused by hypoxia is an ominous, pre-arrest sign. It needs immediate airway and breathing support and an emergency call.
Answer
A · A sign of severe hypoxia and possible imminent cardiac arrest
22.Pediatric nursing
Answer: B · Worsening heart failure with fluid retention
Why this is the answer
A sudden overnight weight gain with periorbital oedema, tachypnoea and sweating suggests fluid retention from worsening heart failure. Daily weights on the same scale are a key way to monitor fluid status in these infants.
Answer
B · Worsening heart failure with fluid retention
23.Mental health nursing
Answer: B · Keeping an emergency bag with documents, money and keys somewhere safe
Why this is the answer
A safety plan includes an escape bag, important documents, a safe place to go, emergency numbers and a code word with trusted people. The time of leaving can be the most dangerous period.
Answer
B · Keeping an emergency bag with documents, money and keys somewhere safe
24.Mental health nursing
Answer: B · Refeeding syndrome
Why this is the answer
Refeeding after starvation causes insulin release that drives phosphate, potassium and magnesium into cells, causing heart failure, oedema, arrhythmias and confusion. Electrolytes are monitored closely and replaced, and feeding is increased gradually.
Answer
B · Refeeding syndrome
25.Nursing math & unit conversions
Answer: x = 0.73 mL
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 hundredths place
0.73223 → 3
Only the next digit decides
0.73223 → 2
2 is 4 or less, so 3 stays.
The digits after it (23) are ignored: round once, never step by step.
Round
x = 0.73 mL
Answer
x = 0.73 mL
26.Nursing math & unit conversions
Answer: V = 562.5 mL
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.
Each item in mL
2 cups = 2·240 = 480 mL
2 fl oz = 2·30 = 60 mL
1½ tbsp = 1.5·15 = 22.5 mL
Add
V = 480 + 60 + 22.5 = 562.5 mL
Answer
V = 562.5 mL
27.Dosage calculations
Answer: D = 250 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
20·25 = 500 mg
Per dose
D = 500/2 = 250 mg
Answer
D = 250 mg
28.Dosage calculations
Answer: V = 0.86 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 = 860/1000 = 0.86 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.86 mL
29.IV infusion rates
Answer: R = 8 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
10·60 = 600 min
Drip rate
R = 500·10/600 = 8.333 ≈ 8 gtt/min
Answer
R = 8 gtt/min
At the bedside you round to the nearest whole drop: 8 gtt/min.
30.IV infusion rates
Answer: D = 6 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
200/500 = 0.4 mg/mL
Dose rate
D = 0.4·15 = 6 mg/h
Answer
D = 6 mg/h
31.Pediatric & critical-care dosing
Answer: R = 16 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
16·100 = 1 600 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1600/100 = 16 mL/h
Answer
R = 16 mL/h
32.Pediatric & critical-care dosing
Answer: R = 20.3 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
500 mg = 500 000 mcg
500 000/250 = 2000 mcg/mL
Dose per minute and per hour
7.5·90 = 675 mcg/min
675·60 = 40500 mcg/h
Pump rate
R = 40500/2000 = 20.25 ≈ 20.3 mL/h
Answer
R = 20.3 mL/h
33.IV fluids & fluid balance
Answer: B = 705 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 + 200 = 540 mL
ice chips: 100/2 = 50 mL
IV infusion: 80·8 = 640 mL
IV antibiotic: 1·100 = 100 mL
total intake = 1330 mL
Total output
375 + 250 = 625 mL
Balance
B = 1330 − 625 = 705 mL
Answer
B = 705 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 7.8 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
75·2 = 150 mL
500 − 150 = 350 mL left
Second part
350/60 = 5.833 h
Total time
t = 2 + 5.833 = 7.833 ≈ 7.8 h
Answer
t = 7.8 h
That is about 7 h 50 min, so the bag runs out at about 01:50.
35.Clinical assessment scores
Answer: NEWS2 = 4
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 20/min → 0
SpO₂ 96% → 0
on air → 0
SBP 142 mmHg → 0
HR 98/min → 1
alert (A) → 0
T 35.0 °C → 3
Add
NEWS2 = 0 + 0 + 0 + 0 + 1 + 0 + 3 = 4
Answer
NEWS2 = 4
36.Clinical assessment scores
Answer: low
APGAR score: five signs, each scored 0, 1 or 2, checked at 1 and 5 minutes after birth. Appearance (colour): blue or pale 0, pink body with blue extremities 1, pink all over 2. Pulse: absent 0, below 100/min 1, 100/min or more 2. Grimace (reflex irritability): none 0, grimace 1, cry, cough or sneeze 2. Activity (tone): limp 0, some flexion 1, active movement 2. Respiration: absent 0, slow or irregular with a weak cry 1, good with a strong cry 2. A total of 7–10 is reassuring, 4–6 moderately abnormal and 0–3 low.
Score each sign
Appearance: blue or pale skin all over → 0
Pulse: 0 → 0
Grimace: no response to stimulation → 0
Activity: limp limbs with no muscle tone → 0
Respiration: no breathing → 0
Add
APGAR = 0 + 0 + 0 + 0 + 0 = 0
Interpretation
0 → low
Answer
low
Below 7 at 5 minutes, the score is usually repeated every 5 minutes up to 20 minutes.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 31.7 mmol/L
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.
Change in PaCO₂
|62 − 40| = 22 mmHg → 2.2 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·2.2 = 31.7 mmol/L
Answer
HCO₃⁻ = 31.7 mmol/L
38.Arterial blood gas interpretation
Answer: added respiratory acidosis
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
1.5·16 + 8 = 32 → 30–34 mmHg
Compare
measured: 38 mmHg → added respiratory acidosis
Answer
added respiratory acidosis
39.ECG rhythm strip interpretation
Answer: QTc = 0.443 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 11.5 × 0.04 = 0.46 s
RR = 27 × 0.04 = 1.08 s
Bazett’s formula
QTc = 0.46/√1.08 = 0.46/1.039 = 0.443 s
Answer
QTc = 0.443 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (443 ms)
40.ECG rhythm strip interpretation
Answer: dual-chamber (AV) paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 21 small boxes, 1500 ÷ 21 ≈ 71 per minute.
2. Rhythm: regular, every R–R is 0.84 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.16 s after the first one (the programmed AV delay).
5. QRS: 0.14 s, wide, right after the second spike (ventricular pacing).
Interpretation
dual-chamber (AV) paced rhythm
Answer
dual-chamber (AV) paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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