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
Before discharge, what is most important to confirm about the patient's new medicines?
AThat they know the price of each medicine and where to buy it
BThat they know how and when to take them and what to report
CThat they know the chemical name of each drug
DThat they know which company makes each drug
2.Nursing fundamentalsHard
A patient's potassium result is 6.8 mmol/L (6.8 mEq/L). Why is this urgent?
AIt is normal for patients after surgery
BHigh potassium causes only mild muscle cramps that settle without treatment
CIt means the patient urgently needs more potassium
DVery high potassium can cause life-threatening heart arrhythmias
3.Infection control & patient safetyMedium
Which technique is used for suctioning a tracheostomy in hospital?
AClean technique, reusing the catheter during the shift
BNo gloves at all, because the airway already contains bacteria
CSterile technique, with a sterile catheter and sterile glove
DClean technique, with the catheter rinsed in tap water
4.Infection control & patient safetyHard
A nurse has worked three long shifts in a row and feels exhausted. The manager asks the nurse to stay for another shift. What is the most appropriate response?
AAgree without telling anyone about the fatigue
BExplain that fatigue would make care unsafe and decline the extra shift
CAgree and drink extra coffee to stay alert
DAgree, but skip the independent medication checks to save energy on the shift
5.Prioritization & delegationMedium
A malnourished patient admitted with alcohol use disorder needs IV glucose. Which vitamin is given before or with it?
AVitamin C (ascorbic acid)
BVitamin D (calciferol)
CThiamine (vitamin B1)
DVitamin K (phytonadione)
6.Prioritization & delegationHard
An infant is choking and cannot cry or breathe. Which technique is correct?
AAbdominal thrusts, as in adults
BA blind finger sweep of the mouth
CHolding the infant upside down by the feet
DBack blows and chest thrusts
7.Clinical nursingMedium
Which blood result often rises in an upper GI bleed because blood is digested in the gut?
AGlucose
BSodium
CCalcium
DUrea (blood urea nitrogen)
8.Clinical nursingHard
A patient with COPD on high-flow oxygen becomes drowsy with a bounding pulse and flushed skin. Blood gas shows a raised PaCO2 and low pH. What is the most likely cause?
AMetabolic alkalosis from vomiting
BHypercapnic respiratory failure, partly due to excessive oxygen
COpioid allergy
DHypoglycaemia
9.Lab values & electrolytesMedium
A patient on warfarin started eating large daily portions of kale and spinach. The INR has fallen. What advice is most appropriate?
AStop warfarin until the diet is normal
BKeep the intake of vitamin K–rich foods steady from day to day
CDouble the warfarin dose without telling the prescriber
DNever eat green vegetables again
10.Lab values & electrolytesHard
The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?
A"I'll check my temperature rectally to be accurate"
B"I'll avoid people who have a cold or the flu"
C"I'll call the clinic if my temperature rises"
D"I'll wash my hands before eating and after the toilet"
11.PharmacologyMedium
A parent will give a liquid medicine to a child at home. Which advice is safest?
AUse any kitchen teaspoon
BUse the oral syringe or measuring cup supplied with it
CMix the dose into a full bottle of milk
DEstimate the dose by pouring the liquid into a small cup
12.PharmacologyHard
A patient taking digoxin has nausea, yellow-green vision and a dangerous arrhythmia. Which specific treatment can bind the drug?
AFlumazenil
BProtamine sulfate
CIntravenous vitamin K (phytomenadione) given slowly
DDigoxin immune Fab (antibody fragments)
13.Med-surg: cardiovascular & respiratoryMedium
A patient with a mechanical heart valve asks to switch from warfarin to apixaban. What is the correct response?
AAny anticoagulant works equally well once the valve is in place
BAspirin alone can replace warfarin once the valve has healed
CDirect oral anticoagulants are not used for mechanical valves
DMechanical valves do not need anticoagulation after the first month
14.Med-surg: cardiovascular & respiratoryHard
A patient with a confirmed type A aortic dissection is hypertensive and tachycardic while awaiting surgery. Which drug class is usually given first to lower the heart rate and blood pressure?
AAn intravenous fluid bolus
BAn intravenous thrombolytic
COral aspirin
DAn intravenous beta-blocker
15.Med-surg: neuro, endocrine & renalMedium
A patient has just started levetiracetam. Which side effect should the nurse teach them to report?
AOrange discoloration of the urine
BA persistent dry cough at night
CChanges in mood, such as irritability, low mood or anger
DSwelling and overgrowth of the gums around the teeth
16.Med-surg: neuro, endocrine & renalHard
Two days after an ileal conduit was formed, the stoma is dark purple and dry. What should the nurse do?
AReport it urgently, because the stoma may be ischaemic
BChange the bag and check again next week
CRecord it as normal for a new stoma
DApply a warm compress to improve the colour of the stoma
17.Med-surg: GI, perioperative & oncologyMedium
Which finding means a patient is usually ready to leave recovery for the ward?
AStill drowsy and needing a jaw thrust to breathe
BAwake, with a clear airway, stable observations and controlled pain
CSystolic BP falling steadily over the last hour, with a rising pulse rate
DPain score 9/10 and vomiting repeatedly
18.Med-surg: GI, perioperative & oncologyHard
A patient took a large paracetamol (acetaminophen) overdose 6 hours ago and says they feel completely well. Which statement is correct?
ALiver damage after paracetamol occurs only within the first hour or so
BFeeling well means the dose was too small to cause harm
CLiver damage may still develop, and appears only days later
DTreatment is not needed if the patient has not vomited
19.Maternity & obstetric nursingMedium
A woman at 39 weeks with a healthy pregnancy asks about walking in early labour. What is the best advice?
AShe must stay in bed on her back for the whole labour
BWalking will cause the cord to prolapse
CUpright positions always make labour slower
DWalking and upright positions can help progress
20.Maternity & obstetric nursingHard
A preterm baby born at 28 weeks is at risk of intraventricular haemorrhage. Which nursing measure reduces this risk?
AKeeping the head of the cot lower than the feet
BFrequent handling and stimulation to keep the baby alert
CRapid fluid boluses to support blood pressure
DMinimal handling with the head in midline
21.Pediatric nursingMedium
A family has a 2-year-old. Which advice about medicines at home is best?
ACall medicines "sweets" so the child is happy to take them
BLock all medicines away, out of reach and sight, in child-resistant containers
CRely on child-resistant caps alone, since toddlers are not strong enough to open them
DKeep daily medicines in a handbag so they are always at hand
22.Pediatric nursingHard
A child with a central venous catheter for chemotherapy develops fever and rigors shortly after the line is flushed. What should the nurse suspect?
AA normal reaction to the chemotherapy
BA catheter-related bloodstream infection
CAn allergy to the saline flush
DA blocked line that needs more forceful flushing
23.Mental health nursingMedium
According to Maslow's hierarchy of needs, which patient need should a nurse on a mental health ward address first?
AA patient who wants to improve her self-esteem
BA patient who has not eaten or drunk anything for two days
CA patient who wants to find a new hobby
DA patient who feels lonely and wants more visitors
24.Mental health nursingHard
A patient on olanzapine has gained 8 kg in 3 months and reports thirst and passing urine frequently. What should the nurse do?
AAdvise him to drink less water
BStop the olanzapine straight away without telling the prescriber
CReassure him that this is unrelated to the drug
DArrange a blood glucose test and inform the prescriber
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 4 ft 11 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
4 ft 11 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 2 tsp of cough syrup, 6 fl oz of juice, 4 tbsp of liquid supplement. Using the equivalents given, find the total oral intake V in mL.
1 tsp = 5 mL1 fl oz = 30 mL1 tbsp = 15 mL
V = mL
27.Dosage calculationsMedium
How many milligrams of drug m are in 10 mL of a 20% (w/v) solution?
20% w/v10 mL
m = mg
28.Dosage calculationsHard
A patient weighs 30.8 lb. The prescription is 10 mg/kg as a single dose, and the stock contains 200 mg in 5 mL. Using 1 kg = 2.2 lb, what volume V do you give?
30.8 lb10 mg/kg200 mg/5 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
A drip runs at 30 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 2 hours?
30 gtt/min15 gtt/mL2 h
V = mL
30.IV infusion ratesHard
A bag contains 1 g of a drug in 500 mL. The order is 3 mg per minute. At what rate R do you set the pump, in mL/h?
1 g/500 mL3 mg/min
R = mL/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 87 kg. The vial contains 5 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg87 kg5 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 95 kg has an order for nitroglycerin at 5 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 mL5 mcg/min95 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 patient weighs 51 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
51 kg8 hurine: 475 mLurine: 175 mLurine: 400 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag was started at 13:30 and runs by pump at 125 mL/h. How many mL V are left in the bag at 19:30?
1000 mL125 mL/h13:30 → 19:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: yes; gait: impaired; mental status: overestimates or forgets limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 101 kg and is 189 cm tall. Calculate the BMI and click the WHO weight category.
101 kg189 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 78 mmHg (10.4 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 respiratory acidosis: pH 7.22, PaCO₂ 68 mmHg (9.1 kPa), HCO₃⁻ 27 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 7.22PaCO₂ 68 mmHg (9.1 kPa)HCO₃⁻ 27 mmol/L
1acute
2chronic
3acute on chronic
39.ECG rhythm strip interpretationMedium
Interpret this lead II rhythm strip. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1normal sinus rhythm
2sinus rhythm with PVCs
3atrial fibrillation
4first-degree AV block
40.ECG rhythm strip interpretationHard
Interpret this lead II strip with the five steps in order: rate, rhythm, P waves, PR interval, QRS duration. At which step do you find the first abnormal finding? Click it.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1rate
2rhythm
3P waves
4PR interval
5QRS duration
3Solutions
1.Nursing fundamentals
Answer: B · That they know how and when to take them and what to report
Why this is the answer
Safe discharge needs the patient or carer to understand dose, timing, purpose and important side effects. Teach-back and written information help confirm this.
Answer
B · That they know how and when to take them and what to report
2.Nursing fundamentals
Answer: D · Very high potassium can cause life-threatening heart arrhythmias
Why this is the answer
Severe hyperkalaemia can cause cardiac arrest. The result is escalated at once; an ECG and treatment follow, and a repeat sample checks whether the result was falsely raised.
Answer
D · Very high potassium can cause life-threatening heart arrhythmias
3.Infection control & patient safety
Answer: C · Sterile technique, with a sterile catheter and sterile glove
Why this is the answer
In hospital, tracheal suctioning uses sterile technique to avoid introducing organisms into the lower airway. Clean technique may be taught for long-term home care, according to policy.
Answer
C · Sterile technique, with a sterile catheter and sterile glove
4.Infection control & patient safety
Answer: B · Explain that fatigue would make care unsafe and decline the extra shift
Why this is the answer
Long hours and fatigue increase errors and injuries. Nurses have a professional responsibility to judge whether they are fit to work safely and to say so clearly.
Answer
B · Explain that fatigue would make care unsafe and decline the extra shift
5.Prioritization & delegation
Answer: C · Thiamine (vitamin B1)
Why this is the answer
Thiamine deficiency is common in heavy alcohol use, and giving glucose without thiamine can trigger Wernicke encephalopathy. Thiamine is given before or with glucose.
Answer
C · Thiamine (vitamin B1)
6.Prioritization & delegation
Answer: D · Back blows and chest thrusts
Why this is the answer
For a choking infant, the nurse gives cycles of five back blows and five chest thrusts. Abdominal thrusts are not used in infants, and blind finger sweeps can push the object deeper.
Answer
D · Back blows and chest thrusts
7.Clinical nursing
Answer: D · Urea (blood urea nitrogen)
Why this is the answer
Blood proteins digested in the upper GI tract are absorbed and converted to urea, so urea rises out of proportion to creatinine. Urea is part of the Glasgow-Blatchford bleeding score.
Answer
D · Urea (blood urea nitrogen)
8.Clinical nursing
Answer: B · Hypercapnic respiratory failure, partly due to excessive oxygen
Why this is the answer
Uncontrolled oxygen in CO2-retaining patients can worsen hypercapnia and respiratory acidosis. Oxygen should be titrated to 88–92% and medical review sought, possibly for non-invasive ventilation.
Answer
B · Hypercapnic respiratory failure, partly due to excessive oxygen
9.Lab values & electrolytes
Answer: B · Keep the intake of vitamin K–rich foods steady from day to day
Why this is the answer
Vitamin K counteracts warfarin, so a large increase in leafy greens lowers the INR. Patients do not have to avoid these foods, but they should keep the amount consistent so the dose can be set correctly.Checked against:Warfarin · MedlinePlus (NIH) (2026); Taking warfarin · MedlinePlus (NIH) (2025)
Answer
B · Keep the intake of vitamin K–rich foods steady from day to day
10.Lab values & electrolytes
Answer: A · "I'll check my temperature rectally to be accurate"
Why this is the answer
Rectal temperatures, suppositories and enemas are avoided in neutropenia, because injury to the rectal mucosa can let bacteria into the blood. Prompt reporting of fever, hand hygiene and avoiding sick contacts are correct.
Answer
A · "I'll check my temperature rectally to be accurate"
11.Pharmacology
Answer: B · Use the oral syringe or measuring cup supplied with it
Why this is the answer
Kitchen spoons are inaccurate and can cause under- or overdosing. Oral syringes in millilitres are the most accurate, and mixing doses into a whole bottle risks the child not getting the full dose.
Answer
B · Use the oral syringe or measuring cup supplied with it
12.Pharmacology
Answer: D · Digoxin immune Fab (antibody fragments)
Why this is the answer
Digoxin immune Fab binds digoxin in the blood and makes it inactive. It is used for life-threatening toxicity, such as serious arrhythmias or severe hyperkalaemia.
Answer
D · Digoxin immune Fab (antibody fragments)
13.Med-surg: cardiovascular & respiratory
Answer: C · Direct oral anticoagulants are not used for mechanical valves
Why this is the answer
Mechanical valves need lifelong anticoagulation with a vitamin K antagonist such as warfarin. Direct oral anticoagulants caused more clots and bleeding in mechanical valve patients and are contraindicated. Biological valves usually need only short-term anticoagulation.
Answer
C · Direct oral anticoagulants are not used for mechanical valves
14.Med-surg: cardiovascular & respiratory
Answer: D · An intravenous beta-blocker
Why this is the answer
In acute dissection, IV beta-blockers are usually given first to reduce heart rate and the rate of rise of pressure, limiting extension of the tear. Vasodilators may follow once the heart rate is controlled. Antiplatelets, anticoagulants and thrombolytics are avoided. Type A dissection needs urgent surgery.
Answer
D · An intravenous beta-blocker
15.Med-surg: neuro, endocrine & renal
Answer: C · Changes in mood, such as irritability, low mood or anger
Why this is the answer
Levetiracetam is widely used and has few drug interactions, but it can cause mood changes, irritability, depression and, rarely, suicidal thoughts. Patients and families should report these. Gum overgrowth is linked to phenytoin.
Answer
C · Changes in mood, such as irritability, low mood or anger
16.Med-surg: neuro, endocrine & renal
Answer: A · Report it urgently, because the stoma may be ischaemic
Why this is the answer
A dusky, purple or black stoma suggests poor blood supply and possible necrosis. It needs urgent surgical review. A healthy stoma is moist and pink to red, and some swelling is normal at first.
Answer
A · Report it urgently, because the stoma may be ischaemic
17.Med-surg: GI, perioperative & oncology
Answer: B · Awake, with a clear airway, stable observations and controlled pain
Why this is the answer
Discharge criteria include a protected airway, adequate breathing and oxygen saturation, stable vital signs, acceptable pain and nausea control, and no active bleeding, as set by local recovery criteria.
Answer
B · Awake, with a clear airway, stable observations and controlled pain
18.Med-surg: GI, perioperative & oncology
Answer: C · Liver damage may still develop, and appears only days later
Why this is the answer
Early after paracetamol overdose, patients often have no or few symptoms, but liver injury peaks after about 3–4 days. Treatment with acetylcysteine is guided by timed paracetamol levels and the history.
Answer
C · Liver damage may still develop, and appears only days later
19.Maternity & obstetric nursing
Answer: D · Walking and upright positions can help progress
Why this is the answer
Upright positions and mobility in the first stage can shorten labour and reduce the need for epidurals. She can choose positions that feel comfortable.
Answer
D · Walking and upright positions can help progress
20.Maternity & obstetric nursing
Answer: D · Minimal handling with the head in midline
Why this is the answer
Preterm babies have fragile germinal matrix vessels. Minimal handling, midline head position, slight elevation of the head and avoiding rapid fluid or pressure changes help prevent bleeding into the ventricles.
Answer
D · Minimal handling with the head in midline
21.Pediatric nursing
Answer: B · Lock all medicines away, out of reach and sight, in child-resistant containers
Why this is the answer
Toddlers explore by climbing and putting things in their mouths. Medicines should be locked away and put back immediately after use. Calling medicine sweets encourages children to take it on their own.
Answer
B · Lock all medicines away, out of reach and sight, in child-resistant containers
22.Pediatric nursing
Answer: B · A catheter-related bloodstream infection
Why this is the answer
Fever and rigors linked to flushing or use of a central line strongly suggest line infection. Blood cultures are taken (often from the line and a peripheral vein) and IV antibiotics are started urgently, especially if the child is neutropenic.
Answer
B · A catheter-related bloodstream infection
23.Mental health nursing
Answer: B · A patient who has not eaten or drunk anything for two days
Why this is the answer
Maslow places physiological needs, such as food and fluids, before safety, love and belonging, esteem and self-actualisation. A patient who is not eating or drinking has the most basic unmet need.
Answer
B · A patient who has not eaten or drunk anything for two days
24.Mental health nursing
Answer: D · Arrange a blood glucose test and inform the prescriber
Why this is the answer
Olanzapine can cause weight gain, insulin resistance and new diabetes. Thirst and polyuria suggest hyperglycaemia, so glucose is checked and the prescriber reviews the treatment.
Answer
D · Arrange a blood glucose test and inform the prescriber
25.Nursing math & unit conversions
Answer: h = 150 cm
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.
Height in inches
4·12 + 11 = 59 in
Inches to centimetres
h = 59·2.54 = 149.9 ≈ 150 cm
Answer
h = 150 cm
26.Nursing math & unit conversions
Answer: V = 250 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 tsp = 2·5 = 10 mL
6 fl oz = 6·30 = 180 mL
4 tbsp = 4·15 = 60 mL
Add
V = 10 + 180 + 60 = 250 mL
Answer
V = 250 mL
27.Dosage calculations
Answer: m = 2000 mg
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Concentration
20% = 20 g/100 mL = 200 mg/mL
Mass of drug
m = 200·10 = 2000 mg
Answer
m = 2000 mg
28.Dosage calculations
Answer: V = 3.5 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.
Weight in kg
30.8/2.2 = 14 kg
Dose
10·14 = 140 mg
Volume
V = (140/200)·5 = 3.5 mL
Answer
V = 3.5 mL
29.IV infusion rates
Answer: V = 240 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
30·60/15 = 120 mL/h
Volume
V = 120·2 = 240 mL
Answer
V = 240 mL
30.IV infusion rates
Answer: R = 90 mL/h
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
1000 mg/500 mL = 2 mg/mL
Dose per hour
3·60 = 180 mg/h
Pump rate
R = 180/2 = 90 mL/h
Answer
R = 90 mL/h
31.Pediatric & critical-care dosing
Answer: V = 1.4 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
80·87 = 6 960 units
Volume
V = 6960/5000 = 1.392 ≈ 1.4 mL
Answer
V = 1.4 mL
32.Pediatric & critical-care dosing
Answer: R = 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
25 000/250 = 100 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
5·60 = 300 mcg/h
Pump rate
R = 300/100 = 3 mL/h
Answer
R = 3 mL/h
33.IV fluids & fluid balance
Answer: U = 2.57 mL/kg/h
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 urine
475 + 175 + 400 = 1050 mL
Per kilogram per hour
U = 1050/(51·8) = 2.574 ≈ 2.57 mL/kg/h
Answer
U = 2.57 mL/kg/h
34.IV fluids & fluid balance
Answer: V = 250 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
13:30 → 19:30 = 6 h
Volume infused
125·6 = 750 mL
Volume left
V = 1000 − 750 = 250 mL
Answer
V = 250 mL
35.Clinical assessment scores
Answer: MFS = 95
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: yes → 20
gait: impaired → 20
mental status: overestimates or forgets limits → 15
Add
Morse total = 25 + 15 + 0 + 20 + 20 + 15 = 95
Answer
MFS = 95
36.Clinical assessment scores
Answer: overweight
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 = 101/1.89² = 28.27
Category
overweight
Answer
overweight
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 37.3 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
|78 − 40| = 38 mmHg → 3.8 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·3.8 = 37.3 mmol/L
Answer
HCO₃⁻ = 37.3 mmol/L
38.Arterial blood gas interpretation
Answer: acute
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 + 1·2.8 = 26.8 mmol/L
chronic: 24 + 3.5·2.8 = 33.8 mmol/L
Compare
measured: 27 mmol/L → acute
Answer
acute
39.ECG rhythm strip interpretation
Answer: sinus rhythm with PVCs
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: 9 QRS complexes in 6 s, × 10 = 90 per minute.
2. Rhythm: regular (0.68 s) except for the early beats and the pause after each of them.
3. P waves: upright before every narrow QRS; none before the early wide beats.
4. PR interval: 0.16 s, constant, within 0.12–0.20 s.
5. QRS: 0.10 s in the sinus beats; the early beats are wide (0.14 s) and bizarre, with the T wave pointing the other way.
Interpretation
sinus rhythm with PVCs
Answer
sinus rhythm with PVCs
40.ECG rhythm strip interpretation
Answer: rate
Five steps for every strip: 1. rate (300 or 1500 method, or the 6-second method if irregular); 2. rhythm: are the R–R intervals equal; 3. P waves: present, upright in lead II, one before every QRS and all alike; 4. PR interval: 0.12–0.20 s and constant; 5. QRS duration: below 0.12 s. Only after the five steps name the rhythm. Normal sinus rhythm passes all five: 60–100/min, regular, upright P before every QRS, PR 0.12–0.20 s, QRS below 0.12 s.
Five steps
1. Rate: R–R = 14 small boxes, 1500 ÷ 14 ≈ 107 per minute.
2. Rhythm: regular, every R–R is 0.56 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.10 s, narrow (below 0.12 s).
First abnormal step
rate → sinus tachycardia
Answer
rate
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