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
Why might a nurse use silence during a conversation with a patient?
AIt lets the nurse plan the next task
BIt gives the patient time to think and say more
CIt shows the patient that the nurse is busy and wants to move on
DIt ends the conversation politely
2.Nursing fundamentalsHard
Which feature best helps distinguish delirium from dementia?
ADementia starts within hours of an infection
BDelirium starts suddenly and attention fluctuates during the day
CDementia always improves once the underlying cause has been treated
DDelirium always lasts for many years
3.Infection control & patient safetyMedium
A family member will visit a patient on contact precautions. What should the nurse do?
AShow them how to use the gown and gloves and how to clean their hands
BTell them visits are not allowed at all
CTell them precautions only apply to staff
DAsk them to wear an N95 respirator only, with no gown or gloves
4.Infection control & patient safetyHard
A nurse teaches the daughter of a patient with moderate Alzheimer’s disease about home safety. Which statement shows a need for further teaching?
A“I let Mom cook alone on the gas stove because she enjoys it.”
B“I keep her medicines locked away and give each dose to her myself.”
C“She wears an ID bracelet in case she gets lost.”
D“We put locks high up on the outside doors.”
5.Prioritization & delegationMedium
A drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?
ATurn the patient onto their side
BGive a drink of water
CRaise the legs above the heart
DGive an oral anti-sickness tablet
6.Prioritization & delegationHard
A patient had sudden difficulty speaking 45 minutes ago. Which action has the highest priority?
AWait until the neurologist can assess the patient on the morning ward round
BActivate the stroke team for urgent imaging, noting when last known well
CGive aspirin by mouth straight away to limit the clot
DGive water so the patient can take the usual morning medicines
7.Clinical nursingMedium
Which side effect is associated with SGLT2 inhibitors such as dapagliflozin?
ASevere weight gain and fluid retention
BGenital fungal infections
CHair loss
DBradycardia
8.Clinical nursingHard
A patient who speaks little English needs to give consent for a procedure. Their 14-year-old child offers to interpret. What is the best action?
AArrange a professional interpreter
BLet the child interpret to save time
CAsk the patient to sign the form without explanation
DUse gestures and proceed
9.Lab values & electrolytesMedium
Why must vitamin B12 deficiency be ruled out before treating macrocytic anemia with folic acid alone?
AFolic acid makes B12 deficiency anemia much worse within a few days
BFolic acid can fix the anemia while B12-related nerve damage continues
CFolic acid blocks the absorption of all B12 from the diet
DFolic acid causes iron overload when B12 levels are low
10.Lab values & electrolytesHard
A patient has eaten very little for 2 weeks and has received broad-spectrum antibiotics. The INR is now 2.3 without warfarin, and the platelets are normal. What is the most likely cause?
AIron-deficiency anemia
BVitamin K deficiency
CImmune thrombocytopenia
DHemophilia A
11.PharmacologyMedium
An Rh-negative mother gives birth to an Rh-positive baby. When is anti-D immunoglobulin usually given?
AAt least two weeks after the birth
BIt is not needed if the baby is Rh-positive
CWithin 72 hours after the birth
DOnly at the start of the next pregnancy
12.PharmacologyHard
A patient who takes propranolol has anaphylaxis and does not respond to repeated adrenaline doses. Which drug may help?
AGlucagon
BNaloxone
COral cetirizine alone
DMore propranolol
13.Med-surg: cardiovascular & respiratoryMedium
Why must anti-embolism stockings be measured and fitted correctly?
APoorly fitting stockings can cause pressure damage
BLoose stockings make the patient's legs too warm at night
CCorrect fit is needed only to improve the appearance
DTight stockings work better, so the smallest size is always best
14.Med-surg: cardiovascular & respiratoryHard
A patient with a confirmed pulmonary embolism has BP 78/50 mmHg despite fluids, and the right ventricle is dilated on echocardiography. Which treatment is most likely?
AOral apixaban only, started next week
BCompression stockings and bed rest
CAn inhaled bronchodilator
DSystemic thrombolysis
15.Med-surg: neuro, endocrine & renalMedium
A patient takes an SGLT2 inhibitor. Which sick-day advice is correct?
AStop drinking fluids while taking the drug
BPause the drug during illness with vomiting or poor intake
CDouble the dose during illness to control the glucose
DKeep taking it as normal, whatever the illness
16.Med-surg: neuro, endocrine & renalHard
A patient in thyroid storm has a temperature of 40 °C (104 °F). Which measure for the fever is usually avoided?
AAspirin
BParacetamol (acetaminophen)
CFanning with cool air
DCooling blankets
17.Med-surg: GI, perioperative & oncologyMedium
Which group of findings suggests obstruction of the bile duct?
APale urine, dark stools and a flapping tremor
BNormal skin colour with diarrhoea and fever
CRed urine, black stools and a high blood glucose
DJaundice, dark urine, pale stools and itching
18.Med-surg: GI, perioperative & oncologyHard
A surgical patient's MUST score is 3 and the wound is healing slowly. What is the most appropriate action?
ARestrict protein to help the kidneys
BRepeat the score in three months' time
CRefer to the dietitian, start a nutrition plan and monitor intake
DEncourage fasting to reduce wound exudate and the size of the dressing
19.Maternity & obstetric nursingMedium
What should parents be taught about the water for a newborn's bath?
ACheck that it is warm, not hot, before the baby goes in
BLeave the baby briefly if the water is only shallow
CUse very hot water so that germs on the skin are killed
DAdd adult bubble bath to soften the baby's skin
20.Maternity & obstetric nursingHard
A fetus has severe oligohydramnios from the second trimester. Which complication is a major concern for the newborn?
ANeural tube defect
BNeonatal hypoglycaemia
CMacrosomia
DPulmonary hypoplasia
21.Pediatric nursingMedium
Which measure is most important in preventing infection in a child with neutropenia?
AKeeping all visitors, including the parents, out of the child's room
BWearing a mask only when the child has a fever
CCareful hand hygiene by everyone in contact with the child
DGiving routine antibiotics to all family members
22.Pediatric nursingHard
A 3-month-old is gaining weight poorly. The mother says she adds extra water to the formula to make each tin last longer. Besides poor growth, what serious complication is the nurse concerned about?
AVitamin K deficiency bleeding from the extra water
BHigh blood glucose from the sugar in the diluted formula, causing diabetes
CLow sodium from water intoxication, which can cause seizures
DHigh sodium from too much powder, which causes dehydration
23.Mental health nursingMedium
Which general principle applies to patients admitted involuntarily under mental health legislation?
AThey lose all their rights
BThey can be kept in hospital indefinitely without any independent review, as long as one doctor agrees it is needed
CThey keep their rights, except those specifically limited by law, and must be informed of their rights
DThey can never refuse any treatment
24.Mental health nursingHard
The daughter of a man with moderate dementia says she is exhausted, is not sleeping and feels guilty for getting angry with him. What is the most helpful nursing response?
AAcknowledge her strain and discuss support such as respite care and carers' groups
BTell her that good daughters do not get angry with their parents
CAdvise her to take on more responsibility for his care so that she feels less guilty
DSuggest that she stops visiting him for a few months so that she can rest and forget about her guilt
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for an injection gives 8.4161 mL. The rule in this exercise is that volumes of 1 mL or more are rounded to the nearest tenth of a mL. What value x do you record?
8.4161 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads ½ tbsp of an oral suspension every 6 hours for 7 days. Using 1 tbsp = 15 mL, how many mL V are needed for the whole course?
½ tbspevery 6 hours7 days1 tbsp = 15 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 45 kg. The prescribed dose is 10 mg/kg per day, given in 3 equal doses. How many milligrams D are given per dose?
45 kg10 mg/kg/day3× per day
D = mg
28.Dosage calculationsHard
A child weighing 8 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?
8 kg12.5 mg/kg40 mg/1 mL
V = mL
29.IV infusion ratesMedium
A drip runs at 25 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 8 hours?
25 gtt/min15 gtt/mL8 h
V = mL
30.IV infusion ratesHard
500 mg of a drug is diluted in 250 mL and given by gravity through a set of 60 gtt/mL. The order is 150 mg per hour. Find the drip rate R in drops per minute.
500 mg/250 mL150 mg/h60 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 250 mL. The order is 14 units/kg/h for a patient who weighs 95 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL14 units/kg/h95 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 250 mg in 250 mL. The order is 7.5 mcg/kg/min for a patient who weighs 51 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL7.5 mcg/kg/min51 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 86 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 10:00 at 75 mL/h. After 4 hours the rate is changed to 125 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL75 mL/h · 4 h125 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 10, with E3 and V4. What motor score M was recorded, and which response does it describe? Give the number.
GCS 10E3V4
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). At 1 minute after birth, a practice newborn has blue or pale skin all over, no heartbeat, no response to stimulation, limp limbs with no muscle tone and no breathing. Score the APGAR and click how the score is interpreted.
1reassuring
2moderately abnormal
3low
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.43, PaCO₂ 28 mmHg (3.7 kPa) and HCO₃⁻ 18 mmol/L. The primary disorder is respiratory alkalosis. How far is it compensated? Click your answer.
pH 7.43PaCO₂ 28 mmHg (3.7 kPa)HCO₃⁻ 18 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 39 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 39 mmol/L
PaCO₂ = mmHg
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 Fridericia’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
1idioventricular rhythm
2asystole
3junctional rhythm
4ventricular tachycardia
3Solutions
1.Nursing fundamentals
Answer: B · It gives the patient time to think and say more
Why this is the answer
Therapeutic silence gives the patient space to gather their thoughts and express feelings, especially about difficult topics. It is used with attentive body language.
Answer
B · It gives the patient time to think and say more
2.Nursing fundamentals
Answer: B · Delirium starts suddenly and attention fluctuates during the day
Why this is the answer
Delirium develops over hours to days with fluctuating attention and awareness, often from a physical cause. Dementia develops gradually over months or years. People with dementia are at higher risk of delirium.
Answer
B · Delirium starts suddenly and attention fluctuates during the day
3.Infection control & patient safety
Answer: A · Show them how to use the gown and gloves and how to clean their hands
Why this is the answer
Visitors are taught how to put on and remove PPE as required by the policy and how to perform hand hygiene, so they protect themselves and other patients.
Answer
A · Show them how to use the gown and gloves and how to clean their hands
4.Infection control & patient safety
Answer: A · “I let Mom cook alone on the gas stove because she enjoys it.”
Why this is the answer
People with moderate dementia may forget a lit stove, causing fires or burns. Cooking should be supervised, or stove knobs removed or controls disabled. The other statements show good safety planning.
Answer
A · “I let Mom cook alone on the gas stove because she enjoys it.”
5.Prioritization & delegation
Answer: A · Turn the patient onto their side
Why this is the answer
A drowsy patient who vomits can aspirate. Turning them to the side lets vomit drain from the mouth; suction and a prescribed antiemetic follow.
Answer
A · Turn the patient onto their side
6.Prioritization & delegation
Answer: B · Activate the stroke team for urgent imaging, noting when last known well
Why this is the answer
Thrombolysis is time-dependent and needs imaging first to rule out a bleed. The time last known well decides eligibility. Aspirin is not given before imaging, and nothing is given by mouth until swallowing has been screened.
Answer
B · Activate the stroke team for urgent imaging, noting when last known well
7.Clinical nursing
Answer: B · Genital fungal infections
Why this is the answer
SGLT2 inhibitors cause glycosuria, which increases the risk of genital thrush and urinary infections. They can also rarely cause DKA with only modestly raised glucose.
Answer
B · Genital fungal infections
8.Clinical nursing
Answer: A · Arrange a professional interpreter
Why this is the answer
Professional interpreters provide accurate, impartial translation and protect confidentiality. Children and family members should not be used for important clinical discussions such as consent.
Answer
A · Arrange a professional interpreter
9.Lab values & electrolytes
Answer: B · Folic acid can fix the anemia while B12-related nerve damage continues
Why this is the answer
Folic acid can improve the blood picture in B12 deficiency but does not prevent nerve damage. Giving folate alone can therefore mask the deficiency while neurological damage progresses. Both levels are checked before treatment.
Answer
B · Folic acid can fix the anemia while B12-related nerve damage continues
10.Lab values & electrolytes
Answer: B · Vitamin K deficiency
Why this is the answer
Vitamin K comes from the diet and from gut bacteria. Poor intake plus antibiotics can cause vitamin K deficiency, which lowers factors II, VII, IX and X and prolongs the PT/INR. Vitamin K replacement corrects it.Checked against:Vitamin K Deficiency in Neonates and Adults (StatPearls) · StatPearls (NCBI Bookshelf) (2026); Prothrombin time (PT) · MedlinePlus (NIH) (2025)
Answer
B · Vitamin K deficiency
11.Pharmacology
Answer: C · Within 72 hours after the birth
Why this is the answer
Anti-D is given within 72 hours of birth to an Rh-negative mother of an Rh-positive baby. It is also given after events such as miscarriage or abdominal trauma, and often routinely during pregnancy.
Answer
C · Within 72 hours after the birth
12.Pharmacology
Answer: A · Glucagon
Why this is the answer
Beta blockers can make anaphylaxis more severe and resistant to adrenaline. Glucagon acts through its own receptor to increase heart rate and contractility, bypassing the blocked beta receptors.
Answer
A · Glucagon
13.Med-surg: cardiovascular & respiratory
Answer: A · Poorly fitting stockings can cause pressure damage
Why this is the answer
Stockings that are the wrong size or that roll down can act like a tourniquet and cause skin and pressure damage. They are measured to the leg, checked daily, and avoided in significant peripheral arterial disease, severe neuropathy or leg skin damage.
Answer
A · Poorly fitting stockings can cause pressure damage
14.Med-surg: cardiovascular & respiratory
Answer: D · Systemic thrombolysis
Why this is the answer
A PE causing sustained hypotension is high-risk and usually treated with thrombolysis to dissolve the clot quickly, unless contraindicated, when surgical or catheter removal may be used. Stable patients are usually treated with anticoagulation alone.
Answer
D · Systemic thrombolysis
15.Med-surg: neuro, endocrine & renal
Answer: B · Pause the drug during illness with vomiting or poor intake
Why this is the answer
During dehydrating illness, SGLT2 inhibitors increase the risk of DKA, which can occur with only modestly raised glucose, and of acute kidney injury. Patients are taught to pause them until they are eating and drinking normally.
Answer
B · Pause the drug during illness with vomiting or poor intake
16.Med-surg: neuro, endocrine & renal
Answer: A · Aspirin
Why this is the answer
Aspirin (salicylates) displaces thyroid hormone from binding proteins, raising free hormone levels. Paracetamol (acetaminophen) and external cooling are used instead, together with treatment for the storm itself.
Answer
A · Aspirin
17.Med-surg: GI, perioperative & oncology
Answer: D · Jaundice, dark urine, pale stools and itching
Why this is the answer
When bile cannot reach the gut, conjugated bilirubin enters the blood and urine (dark urine), stools lose their colour, and bile salts in the skin cause itching. Causes include gallstones and pancreatic cancer.
Answer
D · Jaundice, dark urine, pale stools and itching
18.Med-surg: GI, perioperative & oncology
Answer: C · Refer to the dietitian, start a nutrition plan and monitor intake
Why this is the answer
A MUST score of 2 or more indicates high risk of malnutrition. Poor nutrition delays healing, so the nurse refers to the dietitian, starts a care plan with food charts and supplements as advised, and rescreens regularly.
Answer
C · Refer to the dietitian, start a nutrition plan and monitor intake
19.Maternity & obstetric nursing
Answer: A · Check that it is warm, not hot, before the baby goes in
Why this is the answer
Bath water should be comfortably warm, about 37 °C (98.6 °F), checked with a thermometer or the elbow, and the baby is never left alone, even in shallow water. Plain water or a mild baby cleanser is used. Some guidance, such as in the US, advises sponge baths until the cord stump has fallen off.
Answer
A · Check that it is warm, not hot, before the baby goes in
20.Maternity & obstetric nursing
Answer: D · Pulmonary hypoplasia
Why this is the answer
Amniotic fluid is breathed in and out by the fetus and is needed for lung growth. Prolonged severe oligohydramnios causes pulmonary hypoplasia and limb contractures from compression.
Answer
D · Pulmonary hypoplasia
21.Pediatric nursing
Answer: C · Careful hand hygiene by everyone in contact with the child
Why this is the answer
Thorough hand hygiene by staff, family and the child is the single most important measure. Avoiding contact with people who are unwell, good mouth and skin care and safe food handling also help.
Answer
C · Careful hand hygiene by everyone in contact with the child
22.Pediatric nursing
Answer: C · Low sodium from water intoxication, which can cause seizures
Why this is the answer
Over-diluted formula gives too few calories and too much free water, which can cause hyponatraemia and seizures. The nurse should also address the underlying problem, for example by linking the family with financial or social support.
Answer
C · Low sodium from water intoxication, which can cause seizures
23.Mental health nursing
Answer: C · They keep their rights, except those specifically limited by law, and must be informed of their rights
Why this is the answer
Laws differ between countries, but involuntary patients generally keep their civil rights, have the right to information, appeal and review, and are treated in the least restrictive way.
Answer
C · They keep their rights, except those specifically limited by law, and must be informed of their rights
24.Mental health nursing
Answer: A · Acknowledge her strain and discuss support such as respite care and carers' groups
Why this is the answer
Caregiver strain is common and can affect both the carer and the patient. Recognising it, and offering respite, practical support and carers' groups, helps the carer continue safely.
Answer
A · Acknowledge her strain and discuss support such as respite care and carers' groups
25.Nursing math & unit conversions
Answer: x = 8.4 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the tenths place
8.4161 → 4
Only the next digit decides
8.4161 → 1
1 is 4 or less, so 4 stays.
The digits after it (61) are ignored: round once, never step by step.
Round
x = 8.4 mL
Answer
x = 8.4 mL
26.Nursing math & unit conversions
Answer: V = 210 mL
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.
Volume per dose
½ tbsp = 0.5·15 = 7.5 mL
Whole course
V = 7.5 mL × 4/day × 7 = 210 mL
Answer
V = 210 mL
27.Dosage calculations
Answer: D = 150 mg
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Total per day
10·45 = 450 mg
Per dose
D = 450/3 = 150 mg
Answer
D = 150 mg
28.Dosage calculations
Answer: V = 2.5 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.
Dose from weight
12.5·8 = 100 mg
Volume
V = (100/40)·1 = 2.5 mL
Answer
V = 2.5 mL
29.IV infusion rates
Answer: V = 800 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
25·60/15 = 100 mL/h
Volume
V = 100·8 = 800 mL
Answer
V = 800 mL
30.IV infusion rates
Answer: R = 75 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
500/250 = 2 mg/mL
Volume per hour
150/2 = 75 mL/h
Drip rate
R = 75·60/60 = 75 gtt/min
Answer
R = 75 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 13.3 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
14·95 = 1 330 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1330/100 = 13.3 mL/h
Answer
R = 13.3 mL/h
32.Pediatric & critical-care dosing
Answer: R = 23 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
250 mg = 250 000 mcg
250 000/250 = 1000 mcg/mL
Dose per minute and per hour
7.5·51 = 382.5 mcg/min
382.5·60 = 22950 mcg/h
Pump rate
R = 22950/1000 = 22.95 ≈ 23 mL/h
Answer
R = 23 mL/h
33.IV fluids & fluid balance
Answer: U = 1.57 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
350 + 475 + 475 + 325 = 1625 mL
Per kilogram per hour
U = 1625/(86·12) = 1.575 ≈ 1.57 mL/kg/h
Answer
U = 1.57 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 5.6 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
75·4 = 300 mL
500 − 300 = 200 mL left
Second part
200/125 = 1.6 h
Total time
t = 4 + 1.6 = 5.6 h
Answer
t = 5.6 h
That is about 5 h 36 min, so the bag runs out at about 15:36.
35.Clinical assessment scores
Answer: M = 3
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Motor score
M = 10 − 3 − 4 = 3
M3: abnormal flexion of the arms (decorticate posture)
Answer
M = 3
36.Clinical assessment scores
Answer: low
APGAR score: five signs, each scored 0, 1 or 2, checked at 1 and 5 minutes after birth. Appearance (colour): blue or pale 0, pink body with blue extremities 1, pink all over 2. Pulse: absent 0, below 100/min 1, 100/min or more 2. Grimace (reflex irritability): none 0, grimace 1, cry, cough or sneeze 2. Activity (tone): limp 0, some flexion 1, active movement 2. Respiration: absent 0, slow or irregular with a weak cry 1, good with a strong cry 2. A total of 7–10 is reassuring, 4–6 moderately abnormal and 0–3 low.
Score each sign
Appearance: blue or pale skin all over → 0
Pulse: 0 → 0
Grimace: no response to stimulation → 0
Activity: limp limbs with no muscle tone → 0
Respiration: no breathing → 0
Add
APGAR = 0 + 0 + 0 + 0 + 0 = 0
Interpretation
0 → low
Answer
low
37.Arterial blood gas interpretation
Answer: fully compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.43: within 7.35–7.45
PaCO₂ 28 mmHg: low (35–45)
HCO₃⁻ 18 mmol/L: low (22–26)
Compensation
fully compensated
Answer
fully compensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 48.3 mmHg
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
0.7·39 + 21 = 48.3 mmHg
Answer
PaCO₂ = 48.3 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: QTc = 0.469 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 = 10.5 × 0.04 = 0.42 s
RR = 18 × 0.04 = 0.72 s
Fridericia’s formula
QTc = 0.42/∛0.72 = 0.42/0.8963 = 0.469 s
Answer
QTc = 0.469 s
Above the usual limits for both men (about 0.45 s) and women (about 0.46 s): prolonged. (469 ms)
40.ECG rhythm strip interpretation
Answer: idioventricular rhythm
More ventricular rhythms: torsades de pointes is a polymorphic ventricular tachycardia, usually 150–250/min, in which the wide complexes change in height and twist around the baseline, pointing up for a few beats and then down. Textbooks link it to a prolonged QT interval, and magnesium sulfate is the drug resuscitation guidelines name for it. An idioventricular rhythm is a ventricular escape rhythm: regular, wide QRS (0.12 s or more), no P waves, at 20–40/min (an accelerated idioventricular rhythm runs at 40–100/min). Monomorphic VT has identical wide complexes at more than 100/min. VF is chaotic, without any repeating complex.
Five steps
1. Rate: R–R = 46 small boxes, 1500 ÷ 46 ≈ 33 per minute.
2. Rhythm: regular, every R–R is 1.84 s.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: 0.20 s, wide (0.12 s or more) and bizarre, with the T wave pointing the other way.
Interpretation
idioventricular rhythm
Answer
idioventricular rhythm
An idioventricular rhythm is an escape rhythm: the ventricles take over because the pacemakers above them have failed.
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