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
Where in the eye should eye drops be placed?
AInto the pocket of the lower eyelid
BInto the inner corner of the eye only
CDirectly onto the centre of the cornea
DOnto the upper eyelid while the eye is shut
2.Nursing fundamentalsHard
A patient with capacity tells the nurse they do not want the operation their family keeps pushing for. What is the nurse's best action?
ALet the family decide, as they know the patient best
BTell the patient to follow the family's advice
CSupport the patient to tell the team their wishes
DSay nothing to avoid a conflict with the family
3.Infection control & patient safetyMedium
Many intensive care units bathe patients daily with chlorhexidine. What is the main purpose?
ATo lower the patient’s body temperature
BTo reduce skin bacteria and bloodstream infections linked to central lines
CTo moisturize dry skin in older patients
DTo treat existing wound infections without the need for antibiotics
4.Infection control & patient safetyHard
A patient with pneumonia has low blood pressure and a raised serum lactate. What does the raised lactate suggest?
APoor tissue perfusion, a sign of sepsis-related shock
BMild dehydration from poor intake, with no further concern
CRecovery from the infection is beginning
DA normal response to having a fever
5.Prioritization & delegationMedium
Before giving a scheduled dose of metoprolol, which assessment is most important?
AApical pulse and blood pressure
BTemperature and the latest pain score
CBowel sounds and urine color
DBlood glucose and weight
6.Prioritization & delegationHard
A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?
AGive prescribed opioids and use positioning and a fan to relieve breathlessness
BStart a series of aggressive tests to find the exact cause of the breathlessness
CLeave the patient alone so they can rest
DWithhold all opioids because they may slow breathing
7.Clinical nursingMedium
Which measure helps reduce the risk of surgical site infection?
ARemoving hair, if needed, with clippers rather than a razor
BShaving the area with a razor the night before surgery
CChanging the wound dressing every hour
DLeaving the patient cool during surgery to slow bacterial growth
8.Clinical nursingHard
A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?
A"I can push a knitting needle down the cast to scratch an itch."
B"I will keep my leg raised on pillows for the first few days."
C"I will keep the cast dry."
D"I will come back if my toes go numb or turn blue."
9.Lab values & electrolytesMedium
Which laboratory value best reflects the cause of confusion in a patient with severe liver disease and a flapping tremor?
AA low serum potassium only
BA raised serum ammonia
CA low serum lipase
DA raised troponin
10.Lab values & electrolytesHard
A patient with a heart murmur and fever has three sets of blood cultures, taken hours apart, all growing the same Streptococcus species. What does this suggest?
AA urinary tract infection that has spread to the skin
BA normal finding in patients with heart murmurs
CContamination of all three samples during collection
DPersistent bacteremia, as in infective endocarditis
11.PharmacologyMedium
During an infusion of a vesicant chemotherapy drug, the patient reports burning, and the site is swollen. What should the nurse do first?
AStop the infusion, leave the cannula in and follow the protocol
BRemove the cannula at once and massage the area firmly
CIncrease the infusion rate to finish quickly
DFlush the line with a large volume of saline
12.PharmacologyHard
The volume of distribution of a drug is very large (for example 500 L in an adult). What does this suggest?
AThe drug is extensively taken up into tissues
BThe drug is quickly excreted by the kidneys
CThe drug cannot be given intravenously
DThe drug stays almost entirely in the plasma compartment
13.Med-surg: cardiovascular & respiratoryMedium
Shortly after a permanent pacemaker is inserted via the subclavian vein, the patient becomes breathless with reduced breath sounds on that side. What complication should be suspected?
APulmonary oedema
BPericarditis
CPneumothorax
DAsthma
14.Med-surg: cardiovascular & respiratoryHard
A patient who started an ACE inhibitor yesterday develops swelling of the lips and tongue and a hoarse voice. What should the nurse do first?
AExplain that this is an expected, harmless side effect
BAssess the airway, call for urgent help and hold further doses
CApply ice to the lips and review again in the morning
DGive the next dose early, as this will settle the swelling quickly
15.Med-surg: neuro, endocrine & renalMedium
How should peritoneal dialysis fluid be warmed before use?
AIn a dedicated dry-heat warmer
BIn a bowl of hot tap water
CIn a microwave oven
DIt should be used cold from the fridge
16.Med-surg: neuro, endocrine & renalHard
A nurse teaches a wheelchair user with a spinal cord injury about skin care. Which statement shows a need for further teaching?
A"I only need to check my skin when something hurts."
B"I will keep my skin clean and dry."
C"I will shift my weight in the chair regularly."
D"I will use a mirror to check my bottom and heels every day."
17.Med-surg: GI, perioperative & oncologyMedium
When is cold therapy most useful for pain?
ADirectly on skin with poor circulation
BFor long-term muscle stiffness, applied continuously for several hours
CSoon after an acute soft tissue injury, to reduce swelling
DOver numb areas where sensation is lost
18.Med-surg: GI, perioperative & oncologyHard
During bowel preparation, an older patient becomes dizzy and confused. Blood tests show sodium 127 mmol/L. What should the nurse do?
AStop the preparation and escalate to the medical team
BEncourage plain water only, as much as possible
CRecord it and continue as planned, as this is expected
DGive the rest of the preparation more quickly
19.Maternity & obstetric nursingMedium
A woman is about to get out of bed for the first time after birth. What should the nurse do?
AHelp her sit, then stand slowly with support
BLet her walk alone so she feels independent
CWait until day 3 before letting her stand
DAsk her to stand quickly to reduce dizziness
20.Maternity & obstetric nursingHard
A woman on day 2 after a caesarean suddenly has chest pain, breathlessness, a heart rate of 120/min and an oxygen saturation of 90%. What is the priority?
AGive her a laxative for abdominal pressure
BCall for help, sit her up and give oxygen
CAsk her to walk to the bathroom
DTell her to rest and recheck in 4 hours
21.Pediatric nursingMedium
A 6-month-old's left eye turns inwards all the time. What should the nurse do?
AReassure the parents that this always resolves by school age
BAdvise them to wait until the child can read letters
CCover the right eye with a patch at home without review
DRefer the baby to an eye specialist
22.Pediatric nursingHard
A toddler swallowed a button battery 30 minutes ago and seems well. What is the correct action?
AGive a glass of milk and observe at home
BWait for the battery to pass naturally and check the nappies for several days
CMake the toddler vomit
DArrange immediate transfer to emergency care for imaging and removal
23.Mental health nursingMedium
A patient in a manic episode is too busy to sit down to eat. What is the best way to support nutrition?
AOffer high-calorie finger foods and drinks that can be eaten on the move
BWait until the patient asks for food
CInsist that the patient sits at the table for 1 hour
DOffer a large, three-course meal in the busy dining room at the usual set mealtimes
24.Mental health nursingHard
A man is found in a city far from home. He cannot remember who he is or how he got there, but his speech and thinking are otherwise normal. Tests show no head injury or intoxication. What is most likely?
ADelirium
BDissociative amnesia with dissociative fugue
CA manic episode with poor judgement and impulsive travel
DAlzheimer's disease
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A newborn weighs 6 lb 8 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 8 oz1 lb = 16 oz1 kg = 2.2 lb
m = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 23:30 and finishes at 06:10 the next morning (24-hour clock). How many minutes t did it run?
23:3006:10
t = min
27.Dosage calculationsMedium
A vial contains 2 g of powder. The label says: add 7.4 mL of water for injection to give a total volume of 8 mL. The prescription is 150 mg. What volume V of the reconstituted solution do you give?
2 g+ 7.4 mL → 8 mL150 mg
V = mL
28.Dosage calculationsHard
A child weighing 10 kg is prescribed 12.5 mg/kg per dose of an oral suspension that contains 40 mg in 1 mL. What volume V do you give? Round to one decimal place.
10 kg12.5 mg/kg40 mg/1 mL
V = mL
29.IV infusion ratesMedium
1000 mL was ordered over 10 hours. After 6 hours you find that 510 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?
1000 mL / 10 hafter 6 h: 510 mL
R = mL/h
30.IV infusion ratesHard
An infusion of 100 mg in 250 mL runs at 20 mL/h. How many micrograms per minute D does the patient receive?
100 mg/250 mL20 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 60 units/kg for a patient who weighs 102 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
60 units/kg102 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 76 kg has an order for nitroglycerin at 20 mcg/min. The bag contains 25 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
25 mg/250 mL20 mcg/min76 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 10:45 and runs by pump at 100 mL/h. How many mL V are left in the bag at 17:15?
1000 mL100 mL/h10:45 → 17:15
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 12/min, SpO₂ 99% on room air, blood pressure 92/56 mmHg, pulse 82/min, alert, temperature 37.3 °C. What is the NEWS2 total score?
RR 12SpO₂ 99%airSBP 92HR 82AT 37.3 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: completely limited; moisture: very moist; activity: walks occasionally; mobility: slightly limited; nutrition: very poor; friction and shear: no apparent problem. Use the bands 19–23 not at risk, 15–18 mild, 13–14 moderate, 10–12 high and 9 or below very high. Click the risk level.
1not at risk
2mild risk
3moderate risk
4high risk
5very high risk
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 136 mmol/L, glucose 6.6 mmol/L and urea 18.8 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 136 mmol/Lglucose 6.6 mmol/Lurea 18.8 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 40% oxygen shows PaO₂ 75 mmHg (10.0 kPa) and PaCO₂ 53 mmHg (7.1 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
Measure the QT interval on this lead II strip, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QT = s
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1second-degree AV block type I (Wenckebach)
2atrial fibrillation
3second-degree AV block type II
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: A · Into the pocket of the lower eyelid
Why this is the answer
Drops go into the lower conjunctival sac, which is less sensitive than the cornea. Pressing gently on the inner corner afterwards reduces drainage into the nose.
Answer
A · Into the pocket of the lower eyelid
2.Nursing fundamentals
Answer: C · Support the patient to tell the team their wishes
Why this is the answer
As an advocate the nurse makes sure the patient's own wishes are heard. A competent adult decides about their treatment, and the family's views do not override this.
Answer
C · Support the patient to tell the team their wishes
3.Infection control & patient safety
Answer: B · To reduce skin bacteria and bloodstream infections linked to central lines
Why this is the answer
Daily chlorhexidine bathing lowers the number of organisms on the skin, reducing central line-associated bloodstream infections and the spread of resistant bacteria in ICUs.
Answer
B · To reduce skin bacteria and bloodstream infections linked to central lines
4.Infection control & patient safety
Answer: A · Poor tissue perfusion, a sign of sepsis-related shock
Why this is the answer
When tissues are poorly perfused, cells switch to anaerobic metabolism and lactate rises. In a patient with infection and hypotension, this points to septic shock and needs urgent treatment.
Answer
A · Poor tissue perfusion, a sign of sepsis-related shock
5.Prioritization & delegation
Answer: A · Apical pulse and blood pressure
Why this is the answer
Metoprolol can cause bradycardia and hypotension, so the nurse checks the apical pulse and blood pressure first. The dose is held and reported according to the prescribed parameters.
Answer
A · Apical pulse and blood pressure
6.Prioritization & delegation
Answer: A · Give prescribed opioids and use positioning and a fan to relieve breathlessness
Why this is the answer
In palliative care, opioids are used to relieve breathlessness, along with positioning, a fan and calm reassurance. The aim is comfort, not more investigations.
Answer
A · Give prescribed opioids and use positioning and a fan to relieve breathlessness
7.Clinical nursing
Answer: A · Removing hair, if needed, with clippers rather than a razor
Why this is the answer
Razors cause micro-abrasions that increase infection risk, so hair is removed only if necessary with clippers just before surgery. Keeping patients warm and good skin preparation also help.
Answer
A · Removing hair, if needed, with clippers rather than a razor
8.Clinical nursing
Answer: A · "I can push a knitting needle down the cast to scratch an itch."
Why this is the answer
Pushing objects under a cast can injure the skin and cause infection or pressure sores. Elevation, keeping the cast dry and reporting numbness, colour change or increasing pain are correct.
Answer
A · "I can push a knitting needle down the cast to scratch an itch."
9.Lab values & electrolytes
Answer: B · A raised serum ammonia
Why this is the answer
A failing liver cannot convert ammonia into urea, so ammonia builds up and contributes to hepatic encephalopathy. Lactulose is commonly used to lower ammonia absorption from the gut.Checked against:Ammonia Levels · MedlinePlus (NIH) (2026); Loss of brain function - liver disease · MedlinePlus (NIH) (2025)
Answer
B · A raised serum ammonia
10.Lab values & electrolytes
Answer: D · Persistent bacteremia, as in infective endocarditis
Why this is the answer
Several positive cultures with the same organism, taken at different times, show continuous bacteremia, typical of infective endocarditis. Echocardiography is done and prolonged IV antibiotics are started. Contamination usually affects only one bottle.Checked against:Blood culture · MedlinePlus (NIH) (2025)
Answer
D · Persistent bacteremia, as in infective endocarditis
11.Pharmacology
Answer: A · Stop the infusion, leave the cannula in and follow the protocol
Why this is the answer
Suspected extravasation of a vesicant is an emergency. The infusion is stopped, the cannula is left in so that drug can be aspirated, and the protocol, which may include an antidote and cold or warm packs, is followed.
Answer
A · Stop the infusion, leave the cannula in and follow the protocol
12.Pharmacology
Answer: A · The drug is extensively taken up into tissues
Why this is the answer
A Vd far above total body water means the plasma concentration is low because most of the drug sits in tissues (for example fat or muscle), as with digoxin or amiodarone.
Answer
A · The drug is extensively taken up into tissues
13.Med-surg: cardiovascular & respiratory
Answer: C · Pneumothorax
Why this is the answer
Subclavian puncture can injure the pleura and cause a pneumothorax. A chest X-ray is usually taken after implantation. Other complications include haematoma, lead displacement and infection.
Answer
C · Pneumothorax
14.Med-surg: cardiovascular & respiratory
Answer: B · Assess the airway, call for urgent help and hold further doses
Why this is the answer
Angioedema is a rare but potentially life-threatening reaction to ACE inhibitors, caused by bradykinin accumulation. Airway compromise is the priority: call for emergency help, monitor airway and breathing closely, and stop the drug permanently. It can occur even after years of use.
Answer
B · Assess the airway, call for urgent help and hold further doses
15.Med-surg: neuro, endocrine & renal
Answer: A · In a dedicated dry-heat warmer
Why this is the answer
Warming dialysate to body temperature improves comfort. A microwave heats unevenly and can create hot spots; soaking can contaminate the ports. Manufacturer-approved dry heat warmers are used.
Answer
A · In a dedicated dry-heat warmer
16.Med-surg: neuro, endocrine & renal
Answer: A · "I only need to check my skin when something hurts."
Why this is the answer
Patients usually cannot feel pain below the injury, so pain cannot warn them of pressure damage. They need daily skin checks, often with a mirror, regular pressure relief and good skin hygiene.
Answer
A · "I only need to check my skin when something hurts."
17.Med-surg: GI, perioperative & oncology
Answer: C · Soon after an acute soft tissue injury, to reduce swelling
Why this is the answer
Cold reduces swelling, bleeding and nerve conduction in acute injuries. It is wrapped and applied for short periods and avoided on areas with poor circulation or sensation. Heat is better for muscle spasm and stiffness.
Answer
C · Soon after an acute soft tissue injury, to reduce swelling
18.Med-surg: GI, perioperative & oncology
Answer: A · Stop the preparation and escalate to the medical team
Why this is the answer
Bowel preparation can cause dehydration and electrolyte disturbance, including hyponatraemia, especially in older people. Confusion with low sodium needs prompt medical review, and further prep is withheld until assessed.
Answer
A · Stop the preparation and escalate to the medical team
19.Maternity & obstetric nursing
Answer: A · Help her sit, then stand slowly with support
Why this is the answer
Orthostatic hypotension is common after birth. The nurse helps her sit at the edge of the bed, dangle her legs, then stand slowly with assistance and stays close in case she feels faint.
Answer
A · Help her sit, then stand slowly with support
20.Maternity & obstetric nursing
Answer: B · Call for help, sit her up and give oxygen
Why this is the answer
Sudden breathlessness, chest pain, tachycardia and hypoxia suggest pulmonary embolism, a leading cause of maternal death. The nurse calls for urgent help, positions her upright, gives oxygen and prepares for investigations and anticoagulation.
Answer
B · Call for help, sit her up and give oxygen
21.Pediatric nursing
Answer: D · Refer the baby to an eye specialist
Why this is the answer
An occasional squint is common in the first months, but a constant squint, or any squint after about 4–6 months, needs specialist assessment. Without treatment, the brain may suppress the image from the turning eye, causing amblyopia.
Answer
D · Refer the baby to an eye specialist
22.Pediatric nursing
Answer: D · Arrange immediate transfer to emergency care for imaging and removal
Why this is the answer
Button batteries in the oesophagus can cause severe burns within 2 hours. Even a well-looking child needs urgent X-ray and, if the battery is in the oesophagus, endoscopic removal.
Answer
D · Arrange immediate transfer to emergency care for imaging and removal
23.Mental health nursing
Answer: A · Offer high-calorie finger foods and drinks that can be eaten on the move
Why this is the answer
Patients with mania burn a lot of energy and are easily distracted. Portable, nutritious snacks and fluids help, along with monitoring weight and intake.
Answer
A · Offer high-calorie finger foods and drinks that can be eaten on the move
24.Mental health nursing
Answer: B · Dissociative amnesia with dissociative fugue
Why this is the answer
In dissociative fugue, the person travels away and cannot recall their identity or past, usually after a stressful event. Medical causes such as head injury, seizures and substances must be ruled out first.
Answer
B · Dissociative amnesia with dissociative fugue
25.Nursing math & unit conversions
Answer: m = 2.95 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
8 oz/16 = 0.5 lb
6 + 0.5 = 6.5 lb
Pounds to kilograms
m = 6.5/2.2 = 2.955 ≈ 2.95 kg
Answer
m = 2.95 kg
26.Nursing math & unit conversions
Answer: t = 400 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
23:30 → 24:00 = 30 min
After midnight
00:00 → 06:10 = 370 min
Total
t = 30 + 370 = 400 min
Answer
t = 400 min
27.Dosage calculations
Answer: V = 0.6 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration after mixing
2000 mg/8 mL = 250 mg/mL
Volume
V = 150/250 = 0.6 mL
Answer
V = 0.6 mL
28.Dosage calculations
Answer: V = 3.1 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose from weight
12.5·10 = 125 mg
Volume
V = (125/40)·1 = 3.125 ≈ 3.1 mL
Answer
V = 3.1 mL
29.IV infusion rates
Answer: R = 127.5 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
1000/10 = 100 mL/h
New rate
R = 510/4 = 127.5 mL/h
Answer
R = 127.5 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 = 133.3 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
100000 mcg/250 mL = 400 mcg/mL
Dose per hour
20·400 = 8000 mcg/h
Dose per minute
D = 8000/60 = 133.3 mcg/min
Answer
D = 133.3 mcg/min
31.Pediatric & critical-care dosing
Answer: V = 6.1 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
60·102 = 6 120 units
Volume
V = 6120/1000 = 6.12 ≈ 6.1 mL
Answer
V = 6.1 mL
32.Pediatric & critical-care dosing
Answer: R = 12 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
25 000/250 = 100 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
20·60 = 1200 mcg/h
Pump rate
R = 1200/100 = 12 mL/h
Answer
R = 12 mL/h
33.IV fluids & fluid balance
Answer: B = 685 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 + 250 = 590 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1360 mL
Total output
175 + 500 = 675 mL
Balance
B = 1360 − 675 = 685 mL
Answer
B = 685 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 350 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
10:45 → 17:15 = 6.5 h
Volume infused
100·6.5 = 650 mL
Volume left
V = 1000 − 650 = 350 mL
Answer
V = 350 mL
35.Clinical assessment scores
Answer: NEWS2 = 2
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 12/min → 0
SpO₂ 99% → 0
on air → 0
SBP 92 mmHg → 2
HR 82/min → 0
alert (A) → 0
T 37.3 °C → 0
Add
NEWS2 = 0 + 0 + 0 + 2 + 0 + 0 + 0 = 2
Answer
NEWS2 = 2
36.Clinical assessment scores
Answer: moderate risk
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: completely limited → 1
moisture: very moist → 2
activity: walks occasionally → 3
mobility: slightly limited → 3
nutrition: very poor → 1
friction and shear: no apparent problem → 3
Add
Braden total = 1 + 2 + 3 + 3 + 1 + 3 = 13
Risk level
13 → moderate risk
Answer
moderate risk
37.Arterial blood gas interpretation
Answer: Osm = 297 mOsm/kg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Calculated osmolality
Osm = 2·136 + 6.6 + 18.8 = 297.4 ≈ 297 mOsm/kg
Answer
Osm = 297 mOsm/kg
38.Arterial blood gas interpretation
Answer: A–a gradient = 143.9 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
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
8 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 8 × 0.04 s = 0.32 s
Answer
QT = 0.32 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 0.60 s).
40.ECG rhythm strip interpretation
Answer: second-degree AV block type I (Wenckebach)
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.
Five steps
1. Rate: 4 QRS complexes in 6 s, × 10 = 40 per minute.
2. Rhythm: regularly irregular, the QRS complexes come in groups separated by a pause (group beating).
3. P waves: upright and regular (P–P 1.00 s, 60 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: lengthens 0.18 → 0.30 s, then a P wave is not conducted.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
second-degree AV block type I (Wenckebach)
Answer
second-degree AV block type I (Wenckebach)
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