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
What is the purpose of the Z-track technique for intramuscular injections?
AIt makes the injection go into the fatty tissue instead of the muscle
BIt seals the drug in the muscle and stops it leaking into the tissue above
CIt lets the nurse give a larger volume into a small muscle
DIt numbs the skin before the needle goes in
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 makes the potassium inactive in the blood
CIt stops the kidneys from working at once
DIt can cause a fatal cardiac arrest
3.Infection control & patient safetyMedium
An adult with hepatitis A is incontinent of stool. Which precautions are used?
AA protective environment with filtered air
BAirborne precautions in a negative-pressure room with the door closed
CContact precautions in addition to standard precautions
DDroplet precautions with a surgical mask
4.Infection control & patient safetyHard
A handwritten order reads “10U regular insulin subcut now”. What is the nurse’s best action?
AClarify the order, because “U” can be misread
BAsk a nursing assistant to interpret the handwriting
CGive 10 units without question, as written
DGive 100 units, as the order seems to say
5.Prioritization & delegationMedium
A stable adult with normal vital signs has a cut on the hand that needs sutures and nothing else. Which ESI level fits?
ALevel 3
BLevel 4
CLevel 5
DLevel 2
6.Prioritization & delegationHard
A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?
AEncourage the child to play contact sports
BDo not palpate the abdomen
CGive a warm bath with abdominal massage
DMeasure abdominal girth by pressing firmly
7.Clinical nursingMedium
When giving insulin, which statement is correct?
AAlways inject into the same spot for consistent absorption
BInsulin should be shaken hard before use
CRotate injection sites to avoid lipohypertrophy
DRapid-acting insulin is given only at bedtime
8.Clinical nursingHard
A nurse teaches a patient with heart failure about self-care. Which statement shows a need for further teaching?
A"I will report it if I need more pillows to sleep."
B"I will take my water tablet in the morning."
C"I will weigh myself each morning after passing urine."
D"I only need to weigh myself once a month."
9.Lab values & electrolytesMedium
How should a patient collect a clean-catch midstream urine sample?
AFill the cup completely, then add tap water if there is not enough
BCollect the very first urine of the stream directly in the sterile cup
CClean the area, start voiding into the toilet, then catch the middle part
DCollect urine from the toilet bowl after voiding into the toilet
10.Lab values & electrolytesHard
A patient has fatigue, weight loss, darkening of the skin and low blood pressure. Results: sodium 130 mEq/L, potassium 5.6 mEq/L. Which test pattern would confirm primary adrenal insufficiency (Addison disease)?
ALow cortisol with a high ACTH
BHigh cortisol with a high ACTH
CHigh cortisol with a low ACTH
DLow cortisol with a low ACTH
11.PharmacologyMedium
Why is directly observed therapy (DOT) often used for tuberculosis?
AThe drugs work only if a nurse is present
BTB drugs must always be given intravenously in hospital
CTreatment lasts months, and missed doses cause resistance
DPatients with TB cannot swallow tablets
12.PharmacologyHard
Which property makes a drug more likely to cross the blood–brain barrier?
ALarge molecular weight and strong protein binding
BHigh water solubility and strong ionisation
CHigh lipid solubility and small size
DPositive charge at physiological pH
13.Med-surg: cardiovascular & respiratoryMedium
Which vaccinations are usually recommended for people with COPD?
ANo vaccines at all, as they are known to trigger exacerbations
BAnnual influenza and pneumococcal vaccination
CA BCG vaccine every five years
DA yearly tetanus booster only
14.Med-surg: cardiovascular & respiratoryHard
Seconds after an intramuscular injection, a patient becomes pale, sweaty and faint, with a heart rate of 48/min. There is no rash, wheeze or swelling, and they recover quickly when laid flat. What is the most likely cause?
AA tension pneumothorax
BA vasovagal reaction
CAnaphylaxis
DA myocardial infarction
15.Med-surg: neuro, endocrine & renalMedium
Which picture fits Brown-Séquard syndrome?
AParalysis of both legs, with normal sensation everywhere in the body
BWeakness on the same side and loss of pain on the opposite side
CWeakness of both arms with normal strength in the legs
DLoss of all feeling but normal movement on both sides
16.Med-surg: neuro, endocrine & renalHard
A patient taking digoxin has a potassium of 2.9 mmol/L. Why is this especially dangerous?
ALow potassium increases the risk of digoxin toxicity
BDigoxin raises the potassium to dangerous levels
CLow potassium makes digoxin leave the body faster
DDigoxin stops working when potassium is low
17.Med-surg: GI, perioperative & oncologyMedium
Which monitoring is especially important for a patient receiving parenteral nutrition?
ABowel sounds and stool colour only
BPeak flow and visual acuity
CBlood glucose and signs of line infection
DPupil size and limb strength
18.Med-surg: GI, perioperative & oncologyHard
A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?
ACall for urgent anaesthetic help, as the airway is swelling
BLay the patient flat to help them sleep
CEncourage the patient to rest the voice and reassess tomorrow
DGive a warm drink to soothe the throat
19.Maternity & obstetric nursingMedium
A woman at 26 weeks asks which symptom she should report straight away. Which one is a danger sign?
AOccasional heartburn after large meals
BSudden swelling of the face and hands with a headache
CIncreased vaginal discharge that is white and odourless
DMild swelling of the ankles at the end of the day
20.Maternity & obstetric nursingHard
After a severe postpartum haemorrhage, a woman cannot breastfeed because her milk does not come in, and she feels very tired. Which condition should be suspected?
APostpartum thyroiditis
BSheehan syndrome
CMastitis
DBreast engorgement
21.Pediatric nursingMedium
Which finding is expected in a healthy 4-month-old?
APulls to stand while holding on to furniture
BSits steadily without support for several minutes while playing with toys
CHolds the head steady when held upright, with little or no head lag
DSays two or three clear words with meaning
22.Pediatric nursingHard
The mother of a 5-day-old breastfed baby asks how she can tell her baby is getting enough milk. Which answer is best?
AAbout 6 or more wet nappies a day, regular yellow stools and steady weight gain
BThe baby should feed for exactly 10 minutes on each side at every feed, day and night
CHer breasts should always feel full and hard between feeds
DThe baby should sleep through the night without waking for feeds
23.Mental health nursingMedium
A 78-year-old woman who started citalopram two weeks ago is newly confused and drowsy. Which laboratory result would best explain this?
AA high serum potassium
BA low serum cholesterol
CA low serum sodium
DA high haemoglobin
24.Mental health nursingHard
A 30-year-old who used cocaine an hour ago has crushing chest pain and sweating. What is the priority?
ALet him rest, because the pain will pass when the drug wears off
BReassure him that young people do not have heart problems
CTreat it as a possible heart attack, with an urgent ECG and medical review
DGive him a benzodiazepine for the anxiety and send him home to rest once he feels calmer
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 5 ft 6 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
5 ft 6 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A blood glucose result is 80 mg/dL. Using 1 mmol/L = 18 mg/dL for glucose, find c in mmol/L. Round to one decimal place.
80 mg/dL1 mmol/L = 18 mg/dL
c = mmol/L
27.Dosage calculationsMedium
A child weighing 7 kg is prescribed 4 mg/kg of a drug. The stock solution contains 10 mg/mL. Draw up the dose: what volume V do you give?
7 kg4 mg/kg10 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 4500 units of a drug that comes as 10000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
4500 units10000 units/mL
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 120 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
120 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
250 mg of a drug is diluted in 250 mL and given by gravity through a set of 20 gtt/mL. The order is 60 mg per hour. Find the drip rate R in drops per minute.
250 mg/250 mL60 mg/h20 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 500 mL. The order is 20 units/kg/h for a patient who weighs 94 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL20 units/kg/h94 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 99 kg has an order for norepinephrine at 5 mcg/min. The bag contains 4 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
4 mg/250 mL5 mcg/min99 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 patient weighs 54 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
54 kg12 hurine: 375 mLurine: 400 mLwound drain: 50 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 10:00 at 120 mL/h. After 3 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 mL120 mL/h · 3 h60 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: very limited; moisture: very moist; activity: walks frequently; mobility: no limitation; nutrition: adequate; friction and shear: potential problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 115 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?
MAP 65 mmHgSBP 115 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
Practice values: Na⁺ 145 mmol/L, glucose 6.8 mmol/L and urea 9.2 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 145 mmol/Lglucose 6.8 mmol/Lurea 9.2 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.20, PaCO₂ 48 mmHg (6.4 kPa), HCO₃⁻ 18 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.20PaCO₂ 48 mmHg (6.4 kPa)HCO₃⁻ 18 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
Identify the rhythm on this 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
1third-degree (complete) AV block
2asystole
3junctional rhythm
4ventricular fibrillation
3Solutions
1.Nursing fundamentals
Answer: B · It seals the drug in the muscle and stops it leaking into the tissue above
Why this is the answer
Pulling the skin sideways before injecting and releasing it afterwards makes a zigzag track that closes over the needle path, preventing leakage and skin staining.
Answer
B · It seals the drug in the muscle and stops it leaking into the tissue above
2.Nursing fundamentals
Answer: D · 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
D · It can cause a fatal cardiac arrest
3.Infection control & patient safety
Answer: C · Contact precautions in addition to standard precautions
Why this is the answer
Hepatitis A spreads through fecal contamination. For a patient who is incontinent or in diapers, contact precautions are added to standard precautions to prevent spread on hands and surfaces.
Answer
C · Contact precautions in addition to standard precautions
4.Infection control & patient safety
Answer: A · Clarify the order, because “U” can be misread
Why this is the answer
“10U” can be read as 100 or 104 units, a potentially fatal overdose. The nurse clarifies the order and asks for “units” to be written in full. Guessing is never acceptable for insulin.
Answer
A · Clarify the order, because “U” can be misread
5.Prioritization & delegation
Answer: B · Level 4
Why this is the answer
For a stable patient, ESI levels 3 to 5 depend on the expected resources: two or more is level 3, one is level 4 and none is level 5. Simple suturing counts as one resource, so this is level 4.
Answer
B · Level 4
6.Prioritization & delegation
Answer: B · Do not palpate the abdomen
Why this is the answer
Palpating a Wilms tumor can rupture the capsule and spread cancer cells. A sign is often put on the bed to warn staff not to palpate the abdomen.
Answer
B · Do not palpate the abdomen
7.Clinical nursing
Answer: C · Rotate injection sites to avoid lipohypertrophy
Why this is the answer
Rotating sites prevents fatty lumps that make absorption unpredictable. Cloudy insulins are mixed by gentle rolling, not shaking.
Answer
C · Rotate injection sites to avoid lipohypertrophy
8.Clinical nursing
Answer: D · "I only need to weigh myself once a month."
Why this is the answer
Daily weights at the same time with the same scales detect fluid retention early. A rapid gain, worsening breathlessness or needing more pillows should be reported.
Answer
D · "I only need to weigh myself once a month."
9.Lab values & electrolytes
Answer: C · Clean the area, start voiding into the toilet, then catch the middle part
Why this is the answer
Cleaning the urethral area and discarding the first part of the stream reduce contamination from skin and urethral bacteria. The inside of the sterile container must not be touched, and the sample should reach the laboratory promptly.Checked against:Clean catch urine sample · MedlinePlus (NIH) (2024)
Answer
C · Clean the area, start voiding into the toilet, then catch the middle part
10.Lab values & electrolytes
Answer: A · Low cortisol with a high ACTH
Why this is the answer
In primary adrenal insufficiency the adrenal glands fail, so cortisol is low and the pituitary responds with high ACTH, which also darkens the skin. Low cortisol with low ACTH suggests a pituitary cause. An ACTH stimulation test confirms the diagnosis.Checked against:Adrenocorticotropic Hormone (ACTH) · MedlinePlus (NIH) (2023); Cortisol Test · MedlinePlus (NIH) (2024)
Answer
A · Low cortisol with a high ACTH
11.Pharmacology
Answer: C · Treatment lasts months, and missed doses cause resistance
Why this is the answer
Standard TB treatment usually lasts six months or more with several drugs. Poor adherence leads to relapse and multidrug-resistant TB, so supervised dosing improves completion.
Answer
C · Treatment lasts months, and missed doses cause resistance
12.Pharmacology
Answer: C · High lipid solubility and small size
Why this is the answer
Small, lipophilic, non-ionised molecules diffuse across endothelial cell membranes. Charged or large, protein-bound drugs mostly stay out.
Answer
C · High lipid solubility and small size
13.Med-surg: cardiovascular & respiratory
Answer: B · Annual influenza and pneumococcal vaccination
Why this is the answer
Vaccination against influenza, pneumococcus and other respiratory infections recommended in national schedules (such as COVID-19 and, for older adults, RSV) reduces infections and exacerbations in COPD.
Answer
B · Annual influenza and pneumococcal vaccination
14.Med-surg: cardiovascular & respiratory
Answer: B · A vasovagal reaction
Why this is the answer
Vasovagal reactions cause bradycardia, pallor, sweating and fainting, and resolve quickly when lying flat. Anaphylaxis usually causes tachycardia, airway or breathing problems and often skin changes, and does not settle on its own. If in doubt, treat as anaphylaxis.
Answer
B · A vasovagal reaction
15.Med-surg: neuro, endocrine & renal
Answer: B · Weakness on the same side and loss of pain on the opposite side
Why this is the answer
Damage to one side of the spinal cord, often from a stab wound, causes motor loss and loss of proprioception on the same side, and loss of pain and temperature on the opposite side. The pain fibres cross soon after entering the cord.
Answer
B · Weakness on the same side and loss of pain on the opposite side
16.Med-surg: neuro, endocrine & renal
Answer: A · Low potassium increases the risk of digoxin toxicity
Why this is the answer
Digoxin binds to the sodium–potassium pump, and low potassium increases this binding. Hypokalaemia therefore raises the risk of toxicity and arrhythmias, even with a normal digoxin level. The potassium is corrected and the patient monitored.
Answer
A · Low potassium increases the risk of digoxin toxicity
17.Med-surg: GI, perioperative & oncology
Answer: C · Blood glucose and signs of line infection
Why this is the answer
PN can cause hyperglycaemia and electrolyte disturbance, and the central line is a route for bloodstream infection. Glucose, electrolytes, fluid balance, weight and temperature are monitored closely.
Answer
C · Blood glucose and signs of line infection
18.Med-surg: GI, perioperative & oncology
Answer: A · Call for urgent anaesthetic help, as the airway is swelling
Why this is the answer
Progressive hoarseness and stridor after a facial or inhalation burn mean the airway is narrowing. Early intubation by an experienced anaesthetist is needed before swelling makes it impossible. The patient is sat up and given oxygen.
Answer
A · Call for urgent anaesthetic help, as the airway is swelling
19.Maternity & obstetric nursing
Answer: B · Sudden swelling of the face and hands with a headache
Why this is the answer
Sudden facial or hand swelling, severe headache, visual changes and upper abdominal pain can signal pre-eclampsia. Mild ankle oedema, white discharge and heartburn are common discomforts.
Answer
B · Sudden swelling of the face and hands with a headache
20.Maternity & obstetric nursing
Answer: B · Sheehan syndrome
Why this is the answer
Sheehan syndrome is pituitary necrosis from severe blood loss and hypotension. Low prolactin causes lactation failure, and other hormone deficiencies cause fatigue, low blood pressure and absent periods.
Answer
B · Sheehan syndrome
21.Pediatric nursing
Answer: C · Holds the head steady when held upright, with little or no head lag
Why this is the answer
By about 4 months most infants have good head control with little head lag when pulled to sit. Sitting without support comes at about 6–8 months, pulling to stand at about 9 months and first words at about 12 months.
Answer
C · Holds the head steady when held upright, with little or no head lag
22.Pediatric nursing
Answer: A · About 6 or more wet nappies a day, regular yellow stools and steady weight gain
Why this is the answer
After the first few days, signs of good intake include at least about 6 heavy wet nappies a day, frequent yellow stools, contented behaviour after feeds and weight gain. Most babies regain their birth weight by about 2 weeks.
Answer
A · About 6 or more wet nappies a day, regular yellow stools and steady weight gain
23.Mental health nursing
Answer: C · A low serum sodium
Why this is the answer
SSRIs can cause hyponatraemia through SIADH, especially in older adults. Confusion, falls and drowsiness after starting an SSRI should prompt a sodium check.
Answer
C · A low serum sodium
24.Mental health nursing
Answer: C · Treat it as a possible heart attack, with an urgent ECG and medical review
Why this is the answer
Cocaine can cause coronary vasospasm, myocardial infarction and arrhythmias, even in young people without heart disease. Chest pain after cocaine use needs urgent cardiac assessment.
Answer
C · Treat it as a possible heart attack, with an urgent ECG and medical review
25.Nursing math & unit conversions
Answer: h = 168 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
5·12 + 6 = 66 in
Inches to centimetres
h = 66·2.54 = 167.6 ≈ 168 cm
Answer
h = 168 cm
26.Nursing math & unit conversions
Answer: c = 4.4 mmol/L
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Convert
c = 80/18 = 4.444 ≈ 4.4 mmol/L
Answer
c = 4.4 mmol/L
27.Dosage calculations
Answer: V = 2.8 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.
Dose from body weight
D = 4·7 = 28 mg
Volume
V = 28/10 = 2.8 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 2.8 mL
28.Dosage calculations
Answer: V = 0.45 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 = 4500/10000 = 0.45 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.45 mL
29.IV infusion rates
Answer: R = 120 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.
Millilitres per minute
120/60 = 2 mL/min
Drip rate
R = 2·60 = 120 gtt/min
Answer
R = 120 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: R = 20 gtt/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
250/250 = 1 mg/mL
Volume per hour
60/1 = 60 mL/h
Drip rate
R = 60·20/60 = 20 gtt/min
Answer
R = 20 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 37.6 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
20·94 = 1 880 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 1880/50 = 37.6 mL/h
Answer
R = 37.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 18.8 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
4 000/250 = 16 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 = 300/16 = 18.75 ≈ 18.8 mL/h
Answer
R = 18.8 mL/h
33.IV fluids & fluid balance
Answer: U = 1.2 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
375 + 400 = 775 mL
Per kilogram per hour
U = 775/(54·12) = 1.196 ≈ 1.2 mL/kg/h
Answer
U = 1.2 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 5.3 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
120·3 = 360 mL
500 − 360 = 140 mL left
Second part
140/60 = 2.333 h
Total time
t = 3 + 2.333 = 5.333 ≈ 5.3 h
Answer
t = 5.3 h
That is about 5 h 20 min, so the bag runs out at about 15:20.
35.Clinical assessment scores
Answer: B = 17
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: very limited → 2
moisture: very moist → 2
activity: walks frequently → 4
mobility: no limitation → 4
nutrition: adequate → 3
friction and shear: potential problem → 2
Add
Braden total = 2 + 2 + 4 + 4 + 3 + 2 = 17
Answer
B = 17
36.Clinical assessment scores
Answer: DBP = 40 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·65 − 115)/2 = 80/2 = 40 mmHg
Answer
DBP = 40 mmHg
37.Arterial blood gas interpretation
Answer: Osm = 306 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 = 2·145 + 6.8 + 9.2 = 306 ≈ 306 mOsm/kg
Answer
Osm = 306 mOsm/kg
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
1.5·18 + 8 = 35 → 33–37 mmHg
Compare
measured: 48 mmHg → added respiratory acidosis
Answer
added respiratory acidosis
39.ECG rhythm strip interpretation
Answer: QTc = 0.485 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 = 10 × 0.04 = 0.40 s
RR = 17 × 0.04 = 0.68 s
Bazett’s formula
QTc = 0.40/√0.68 = 0.40/0.8246 = 0.485 s
Answer
QTc = 0.485 s
Above the usual limits for both men (about 0.45 s) and women (about 0.46 s): prolonged. (485 ms)
40.ECG rhythm strip interpretation
Answer: asystole
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
Five steps
1. Rate: no countable ventricular rate.
2. Rhythm: none; an almost flat line.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: no QRS complexes.
Interpretation
asystole
Answer
asystole
A flat line is always checked: look at the patient, the leads and the gain, and view a second lead, because a loose electrode or fine VF can look like asystole.
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