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 should reddened skin over a bony area not be massaged?
AMassage hides early signs of infection
BMassage can damage the deeper tissues further
CMassage is only allowed when done by a physiotherapist
DMassage makes the redness spread to other areas
2.Nursing fundamentalsHard
A patient rescued from a house fire has a pulse oximetry reading of 99% but is drowsy and has a headache. Why may the reading be falsely reassuring?
ABurns make the skin conduct light better
BCarbon monoxide bound to haemoglobin is read by the oximeter as oxygen
CThe patient's heart rate is too fast for the device to give an accurate reading
DSmoke makes the oximeter read too low
3.Infection control & patient safetyMedium
Which nurse should not be assigned to a patient with a sealed radioactive implant?
AA nurse who has worked on the unit for two years
BA nurse wearing a dosimeter badge
CA nurse who is pregnant
DA nurse trained in radiation safety
4.Infection control & patient safetyHard
A patient’s WBC is 4,000/mm3, with 30% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)?
A3,500/mm3
B140/mm3
C1,200/mm3
D1,400/mm3
5.Prioritization & delegationMedium
Several patients on a gastroenterology unit need care. Which patient should the nurse see first?
ALong-standing back pain, asking for the usual analgesic
BTwo hours after a colonoscopy: rigid abdomen and severe new pain
CUlcerative colitis, asking about diet changes for home
DCrohn disease, waiting to be taken down for a scheduled CT scan
6.Prioritization & delegationHard
An RN sees an LPN/LVN crushing an extended-release metoprolol tablet to mix with applesauce. What should the RN do?
AStop the LPN/LVN and contact the prescriber or pharmacist about another form
BLet the LPN/LVN continue, since crushing makes the tablet easier to swallow
CReport the LPN/LVN at the end of the month without saying anything now
DTell the LPN/LVN to give half of the crushed tablet now and the other half at lunchtime
7.Clinical nursingMedium
A confused patient keeps trying to climb out of bed. Why are bed rails not automatically the answer?
APatients can be seriously injured climbing over or becoming trapped in rails
BBed rails stop staff from taking observations
CBed rails always make patients more confused, but only during the day
DBed rails are illegal in all hospitals and must never be used at all
8.Clinical nursingHard
A patient with central chest pain has ST elevation on the 12-lead ECG. What is the main aim of urgent treatment?
ARestoring blood flow through the blocked coronary artery quickly
BStrict bed rest for several days before deciding on treatment
CWaiting for the troponin result before taking any action
DStarting a cholesterol-lowering drug before any other treatment is given
9.Lab values & electrolytesMedium
A patient with hyperkalemia is prescribed an oral potassium binder such as patiromer or sodium zirconium cyclosilicate. How does this drug lower potassium?
AIt protects the heart muscle against high potassium levels
BIt stops the kidneys from absorbing water in the tubules
CIt binds potassium in the gut so it leaves in the stool
DIt moves potassium into cells in the next few minutes
10.Lab values & electrolytesHard
A patient with thalassemia major has received regular red cell transfusions for years. The ferritin is now very high. What does this most likely show, and what treatment is used?
AIron overload, treated with iron chelation therapy
BLiver failure, treated with a liver transplant at once
CIron deficiency, treated with IV iron supplements
DAcute infection, treated with broad-spectrum antibiotics
11.PharmacologyMedium
A prescriber gives a verbal medication order in an emergency. What should the nurse do?
AGive the drug without recording the order
BAsk another nurse to remember the order
CWrite it down and read it back to the prescriber to confirm
DRemember it and write it in the chart at the end of the shift
12.PharmacologyHard
A drug has a volume of distribution of 40 L and complete bioavailability. Which loading dose gives a target plasma concentration of 2 mg/L?
A80 mg
B160 mg
C42 mg
D20 mg
13.Med-surg: cardiovascular & respiratoryMedium
How is a patient usually positioned for a thoracentesis?
ASitting upright and leaning forward over a table
BLying on the affected side with the head down
CProne with the arms by the sides
DFlat on the back with the legs raised
14.Med-surg: cardiovascular & respiratoryHard
A patient with small-cell lung cancer becomes confused. Sodium is 122 mmol/L (122 mEq/L) with concentrated urine, and there are no signs of dehydration. What is the most likely cause?
ACranial diabetes insipidus from brain metastases
BSyndrome of inappropriate ADH secretion
CSevere dehydration from poor oral intake
DExcess salt in the diet over several weeks
15.Med-surg: neuro, endocrine & renalMedium
An 82-year-old taking apixaban fell three weeks ago. Since then their family has noticed increasing confusion and headaches. Which condition is most likely?
ASubarachnoid haemorrhage from an aneurysm
BNormal ageing with mild memory loss
CAcute extradural haematoma
DChronic subdural haematoma
16.Med-surg: neuro, endocrine & renalHard
A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?
AFood is absorbed slowly, so the insulin peaks before the glucose rises
BThe insulin has gone off and needs replacing
CThe meter gives false results for several hours after every meal
DThe patient is secretly eating sweets between meals
17.Med-surg: GI, perioperative & oncologyMedium
Which technique is correct when giving a prefilled low molecular weight heparin injection?
ARub the site firmly afterwards to help absorption
BExpel the air bubble first and inject into the deltoid muscle
CInject into a vein in the back of the hand
DLeave the air bubble in and inject into a skin fold
18.Med-surg: GI, perioperative & oncologyHard
An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?
AIncontinence-associated dermatitis
BA category 4 pressure ulcer over the sacrum
CA full-thickness burn
DAn arterial ulcer caused by poor circulation
19.Maternity & obstetric nursingMedium
Why is tight glucose control before conception important in women with pre-existing diabetes?
AIt guarantees that the baby will be born at term
BIt prevents the mother from developing pre-eclampsia
CEarly hyperglycaemia raises the risk of birth defects
DIt prevents the need for any monitoring during pregnancy
20.Maternity & obstetric nursingHard
The nurse must deliver a baby before the provider arrives. As the head crowns, what should the nurse do?
APull firmly on the head to speed the birth
BApply gentle pressure to the head to slow the birth
CPush the head back to delay the birth
DAsk the woman to cross her legs tightly until help comes
21.Pediatric nursingMedium
Which drink is best for a child with mild dehydration from gastroenteritis?
ACola or other fizzy drinks
BOral rehydration solution
CSports drinks
DUndiluted apple juice
22.Pediatric nursingHard
A child who had a tonsillectomy this morning is swallowing frequently and spitting up bright red blood. What should the nurse do first?
AGive a warm drink to soothe the throat
BAssess the throat and vital signs and notify the surgeon urgently
CRecord it in the notes and reassess at the next routine observation round
DEncourage the child to gargle
23.Mental health nursingMedium
Which medicine is most likely to raise a patient's lithium level?
AIbuprofen
BParacetamol (acetaminophen)
CAmoxicillin
DOmeprazole
24.Mental health nursingHard
A woman who is being abused by her partner says she will not leave him. What is the most appropriate response?
ARespect her decision, give information about support services and help her make a safety plan
BTell her that she must leave him today or the nurse cannot help her
CCall her partner to discuss his behaviour with him
DTell her that if she stays and is hurt again, it will be her own fault because she was warned about the risks
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 35.8 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
35.8 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads ½ tsp of an oral suspension every 12 hours for 14 days. The suspension comes in 150 mL bottles. Using 1 tsp = 5 mL, how many whole bottles N must be supplied so the course is complete?
½ tspevery 12 hours14 days150 mL1 tsp = 5 mL
N =
27.Dosage calculationsMedium
A child weighing 24 kg is prescribed 3 mg/kg of a drug. The stock solution contains 20 mg/mL. Draw up the dose: what volume V do you give?
24 kg3 mg/kg20 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 1.36 mg. The ampoule contains 2000 micrograms per mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
1.36 mg2000 mcg/mL
V = mL
29.IV infusion ratesMedium
Infuse 1000 mL over 2 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1000 mL2 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
500 mL was ordered over 10 hours. After 2 hours you find that 460 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
500 mL / 10 hafter 2 h: 460 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 20 units/kg/h for a patient who weighs 53 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL20 units/kg/h53 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 500 mg in 250 mL runs at 35 mL/h. The patient weighs 62 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
500 mg/250 mL35 mL/h62 kg
D = mcg/kg/min
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
soup: 200 mLmilk: 200 mLwater: 350 mLIV infusion: 50 mL/h × 8 hIV antibiotic: 1 × 50 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 75 mL/h. At 11:30, 350 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL350 mL infused75 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 10/min, SpO₂ 91% on room air, blood pressure 102/62 mmHg, pulse 64/min, alert, temperature 39.2 °C. What is the NEWS2 total score?
RR 10SpO₂ 91%airSBP 102HR 64AT 39.2 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 18/min, SpO₂ 91% on room air, blood pressure 136/82 mmHg, pulse 82/min, alert, temperature 37.0 °C. Which clinical risk group does the patient fall into? Click it.
RR 18SpO₂ 91%airSBP 136HR 82AT 37.0 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.57, PaCO₂ 37 mmHg (4.9 kPa) and HCO₃⁻ 33 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.57PaCO₂ 37 mmHg (4.9 kPa)HCO₃⁻ 33 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 40% oxygen shows PaO₂ 74 mmHg (9.9 kPa) and PaCO₂ 59 mmHg (7.9 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
This lead II strip shows sinus rhythm with one pause. Measure the pause, the R–R interval across it, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
pause = s
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. The QRS complexes are regular: find the ventricular rate in beats per minute (1500 method, whole number).
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ventricular rate = bpm
3Solutions
1.Nursing fundamentals
Answer: B · Massage can damage the deeper tissues further
Why this is the answer
Massaging red, pressure-damaged areas can tear small blood vessels and worsen tissue damage. Pressure is relieved by repositioning instead.
Answer
B · Massage can damage the deeper tissues further
2.Nursing fundamentals
Answer: B · Carbon monoxide bound to haemoglobin is read by the oximeter as oxygen
Why this is the answer
Carboxyhaemoglobin absorbs light much like oxyhaemoglobin, so standard pulse oximeters overestimate oxygen saturation. Arterial blood gas with co-oximetry is needed, and high-flow oxygen is given.
Answer
B · Carbon monoxide bound to haemoglobin is read by the oximeter as oxygen
3.Infection control & patient safety
Answer: C · A nurse who is pregnant
Why this is the answer
Pregnant staff and visitors are not assigned to patients with radioactive implants. Other staff limit the time spent with the patient, keep their distance, use shielding and wear a dosimeter.
Answer
C · A nurse who is pregnant
4.Infection control & patient safety
Answer: D · 1,400/mm3
Why this is the answer
ANC = 4,000 × (0.30 + 0.05) = 1,400/mm3. This is below normal (neutropenia), so the patient has a raised risk of infection.
Answer
D · 1,400/mm3
5.Prioritization & delegation
Answer: B · Two hours after a colonoscopy: rigid abdomen and severe new pain
Why this is the answer
A rigid abdomen with severe pain after colonoscopy suggests bowel perforation and peritonitis, a surgical emergency. The other patients have stable, chronic or routine needs.
Answer
B · Two hours after a colonoscopy: rigid abdomen and severe new pain
6.Prioritization & delegation
Answer: A · Stop the LPN/LVN and contact the prescriber or pharmacist about another form
Why this is the answer
Crushing an extended-release tablet releases the whole dose at once and can cause toxicity, such as severe bradycardia or hypotension. The RN steps in now and arranges a suitable form.
Answer
A · Stop the LPN/LVN and contact the prescriber or pharmacist about another form
7.Clinical nursing
Answer: A · Patients can be seriously injured climbing over or becoming trapped in rails
Why this is the answer
Bed rails can cause entrapment or a fall from a greater height. Their use is based on an individual risk assessment; alternatives include a low bed, crash mats and closer observation.
Answer
A · Patients can be seriously injured climbing over or becoming trapped in rails
8.Clinical nursing
Answer: A · Restoring blood flow through the blocked coronary artery quickly
Why this is the answer
ST-elevation myocardial infarction means a coronary artery is usually completely blocked. Urgent reperfusion by primary PCI, or thrombolysis if PCI is not available in time, limits the amount of heart muscle that dies.
Answer
A · Restoring blood flow through the blocked coronary artery quickly
9.Lab values & electrolytes
Answer: C · It binds potassium in the gut so it leaves in the stool
Why this is the answer
Potassium binders exchange potassium in the gut for another ion, so potassium is removed from the body in the stool. They act over hours, so they are not used alone for emergencies; calcium protects the heart, and insulin with glucose shifts potassium into cells quickly.Checked against:High potassium level · MedlinePlus (NIH) (2025)
Answer
C · It binds potassium in the gut so it leaves in the stool
10.Lab values & electrolytes
Answer: A · Iron overload, treated with iron chelation therapy
Why this is the answer
The body has no active way to excrete iron, so repeated transfusions cause iron overload, which can damage the heart, liver and endocrine glands. A very high ferritin reflects this, and iron chelators are used to remove the excess.Checked against:Thalassemia · MedlinePlus (NIH) (2026); Ferritin Blood Test · MedlinePlus (NIH) (2025)
Answer
A · Iron overload, treated with iron chelation therapy
11.Pharmacology
Answer: C · Write it down and read it back to the prescriber to confirm
Why this is the answer
Reading back the drug, dose, route and frequency confirms the order and catches errors. Verbal orders are documented immediately and signed by the prescriber according to policy.
Answer
C · Write it down and read it back to the prescriber to confirm
12.Pharmacology
Answer: A · 80 mg
Why this is the answer
Loading dose = 40 L × 2 mg/L = 80 mg. The loading dose depends on Vd, while the maintenance dose depends on clearance.
Answer
A · 80 mg
13.Med-surg: cardiovascular & respiratory
Answer: A · Sitting upright and leaning forward over a table
Why this is the answer
Sitting upright and leaning forward on a bedside table widens the intercostal spaces at the back and lets the fluid settle at the base. If the patient cannot sit, lying on the unaffected side may be used.
Answer
A · Sitting upright and leaning forward over a table
14.Med-surg: cardiovascular & respiratory
Answer: B · Syndrome of inappropriate ADH secretion
Why this is the answer
Small-cell lung cancer can secrete ADH, causing water retention and dilutional hyponatraemia (normal sodium about 135–145 mmol/L). Urine is inappropriately concentrated and the patient is not dry. Fluid restriction and treating the cancer are the main measures; sodium is corrected slowly to avoid osmotic demyelination.
Answer
B · Syndrome of inappropriate ADH secretion
15.Med-surg: neuro, endocrine & renal
Answer: D · Chronic subdural haematoma
Why this is the answer
Older people have brain atrophy that stretches the bridging veins, and anticoagulants increase bleeding. A slow venous bleed can cause gradual confusion, headache or weakness over weeks. A CT scan is needed.
Answer
D · Chronic subdural haematoma
16.Med-surg: neuro, endocrine & renal
Answer: A · Food is absorbed slowly, so the insulin peaks before the glucose rises
Why this is the answer
Delayed gastric emptying means carbohydrate reaches the blood later than expected. The insulin acts too early, causing a hypo, and glucose rises later. The prescriber may change the timing, for example giving the insulin after the meal.
Answer
A · Food is absorbed slowly, so the insulin peaks before the glucose rises
17.Med-surg: GI, perioperative & oncology
Answer: D · Leave the air bubble in and inject into a skin fold
Why this is the answer
LMWH is injected into a pinched skin fold, often on the abdomen, away from the umbilicus. The air bubble in prefilled syringes is left in, and the site is not rubbed, to reduce bruising.
Answer
D · Leave the air bubble in and inject into a skin fold
18.Med-surg: GI, perioperative & oncology
Answer: A · Incontinence-associated dermatitis
Why this is the answer
Incontinence-associated dermatitis is inflammation from urine or faeces, with diffuse redness and superficial erosion. It is managed with gentle cleansing, barrier products and managing incontinence, and is different from a pressure ulcer.
Answer
A · Incontinence-associated dermatitis
19.Maternity & obstetric nursing
Answer: C · Early hyperglycaemia raises the risk of birth defects
Why this is the answer
Hyperglycaemia during organogenesis increases the risk of heart, neural tube and other anomalies and of miscarriage. Good preconception control and high-dose folic acid lower this risk.
Answer
C · Early hyperglycaemia raises the risk of birth defects
20.Maternity & obstetric nursing
Answer: B · Apply gentle pressure to the head to slow the birth
Why this is the answer
Gentle pressure on the fetal head, with the woman panting, slows birth and reduces perineal tearing and rapid pressure changes in the fetal skull. The nurse then checks for a nuchal cord and supports the baby's body.
Answer
B · Apply gentle pressure to the head to slow the birth
21.Pediatric nursing
Answer: B · Oral rehydration solution
Why this is the answer
Oral rehydration solution has the right balance of sodium and glucose to promote water absorption. Juice, fizzy drinks and many sports drinks contain too much sugar and too little sodium and can worsen diarrhoea.
Answer
B · Oral rehydration solution
22.Pediatric nursing
Answer: B · Assess the throat and vital signs and notify the surgeon urgently
Why this is the answer
Frequent swallowing and bright red blood suggest postoperative haemorrhage. Keep the child upright or on their side, assess vital signs and the throat with a light, and inform the surgeon at once.
Answer
B · Assess the throat and vital signs and notify the surgeon urgently
23.Mental health nursing
Answer: A · Ibuprofen
Why this is the answer
NSAIDs, thiazide diuretics and ACE inhibitors reduce lithium clearance and can cause toxicity. Paracetamol is usually preferred for mild pain in patients on lithium.
Answer
A · Ibuprofen
24.Mental health nursing
Answer: A · Respect her decision, give information about support services and help her make a safety plan
Why this is the answer
Adults have the right to make their own decisions. Many survivors leave and return several times. The nurse documents carefully, provides resources and a safety plan, and keeps the door open for future help.
Answer
A · Respect her decision, give information about support services and help her make a safety plan
25.Nursing math & unit conversions
Answer: T = 96.4 °F
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Multiply by 9/5
35.8·9/5 = 64.44
Add 32
T = 64.44 + 32 = 96.44 ≈ 96.4 °F
Answer
T = 96.4 °F
26.Nursing math & unit conversions
Answer: N = 1
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.
Total volume
2.5 mL × 2 × 14 = 70 mL
Bottles
70/150 = 0.4667 → N = 1
Answer
N = 1
27.Dosage calculations
Answer: V = 3.6 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 = 3·24 = 72 mg
Volume
V = 72/20 = 3.6 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 3.6 mL
28.Dosage calculations
Answer: V = 0.68 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.
Same units
1.36 mg = 1360 mcg
Volume
V = 1360/2000 = 0.68 mL
Answer
V = 0.68 mL
29.IV infusion rates
Answer: R = 83 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Time in minutes
2·60 = 120 min
Drip rate
R = 1000·10/120 = 83.33 ≈ 83 gtt/min
Answer
R = 83 gtt/min
At the bedside you round to the nearest whole drop: 83 gtt/min.
30.IV infusion rates
Answer: Δ = 15 %
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
500/10 = 50 mL/h
New rate
R = 460/8 = 57.5 mL/h
Percentage change
Δ = (57.5 − 50)/50·100% = 15%
Answer
Δ = 15%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: R = 26.5 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
20·53 = 1 060 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1060/40 = 26.5 mL/h
Answer
R = 26.5 mL/h
32.Pediatric & critical-care dosing
Answer: D = 18.8 mcg/kg/min
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
500 000/250 = 2000 mcg/mL
Micrograms per minute
35·2000 = 70000 mcg/h
70000/60 = 1167 mcg/min
Per kilogram
D = 1167/62 = 18.82 ≈ 18.8 mcg/kg/min
Answer
D = 18.8 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 1200 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Add the intake
oral: 200 + 200 + 350 = 750 mL
IV infusion: 50·8 = 400 mL
IV antibiotic: 1·50 = 50 mL
I = 1200 mL
Answer
I = 1200 mL
34.IV fluids & fluid balance
Answer: t = 8.7 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.
Volume left
1000 − 350 = 650 mL
Time
t = 650/75 = 8.667 ≈ 8.7 h
Answer
t = 8.7 h
That is about 8 h 40 min, so the bag runs out at about 20:10.
35.Clinical assessment scores
Answer: NEWS2 = 7
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 10/min → 1
SpO₂ 91% → 3
on air → 0
SBP 102 mmHg → 1
HR 64/min → 0
alert (A) → 0
T 39.2 °C → 2
Add
NEWS2 = 1 + 3 + 0 + 1 + 0 + 0 + 2 = 7
Answer
NEWS2 = 7
36.Clinical assessment scores
Answer: low–medium
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 18/min → 0
SpO₂ 91% → 3
on air → 0
SBP 136 mmHg → 0
HR 82/min → 0
alert (A) → 0
T 37.0 °C → 0
Total and red scores
NEWS2 = 0 + 3 + 0 + 0 + 0 + 0 + 0 = 3
At least one parameter scores 3.
Risk group
low–medium
Answer
low–medium
A single score of 3 needs an urgent review even when the total is low.
37.Arterial blood gas interpretation
Answer: uncompensated
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 7.57: alkalaemia (above 7.45)
PaCO₂ 37 mmHg: normal (35–45)
HCO₃⁻ 33 mmol/L: high (22–26)
Compensation
Clinically, also check the expected compensation: for a metabolic alkalosis PaCO₂ ≈ 0.7·HCO₃⁻ + 21 = 42.1–46.1 mmHg, so the measured 37 mmHg points to an additional respiratory alkalosis (a mixed disorder). The answer above is the ROME exam classification.
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: A–a gradient = 137.4 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Measure
43 small boxes from R to R across the pause
Convert
pause = 43 × 0.04 s = 1.72 s
Compare with P–P
1.72 ÷ 0.76 ≈ 2.3 P–P cycles, not a whole number
Answer
pause = 1.72 s
No P wave appears in the pause, and the pause is not a whole number of P–P cycles: sinus arrest. A pause of exactly two or three cycles would point to sinus exit block.
40.ECG rhythm strip interpretation
Answer: ventricular rate = 29 bpm
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Atrial rate
P–P = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 ≈ 75 per minute
Ventricular rate
R–R = 51 small boxes = 2.04 s → 1500 ÷ 51 = 29.41 ≈ 29 per minute
Answer
ventricular rate = 29 bpm
Answer
ventricular rate = 29 bpm
Third-degree block with a wide-complex ventricular escape (usually 20–40 per minute).
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