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
Which nursing record entry is the best example of objective documentation?
A"Had a good appetite today and enjoyed lunch."
B"Ate half of lunch; drank 200 mL of water."
C"Seemed to enjoy the meal."
D"Ate well, as usual."
2.Nursing fundamentalsHard
A severely malnourished patient is about to start feeding. Which complication is a particular risk?
ARefeeding syndrome with low phosphate, potassium and magnesium
BSudden weight gain of several kilograms of fat in the first week
CVery high blood sodium in the first hour
DImmediate allergic reaction to the feed
3.Infection control & patient safetyMedium
While a sterile field is being prepared, the nurse turns away from it to answer a question. What is correct?
AOnly the items nearest the nurse need to be replaced
BThe field is still sterile because nobody touched it in the meantime
CThe field is considered contaminated and must be set up again
DThe field can be used if it is covered afterwards
4.Infection control & patient safetyHard
A nurse picks up a heparin vial that contains 10 000 units/mL; the ward usually stocks 1000 units/mL vials. Why is extra care needed?
AThe concentrated vial is safer, because less volume is drawn up
BHeparin concentration has no effect on safety
CUsing the more concentrated vial by mistake would give a tenfold overdose
DBoth vial strengths can be swapped freely
5.Prioritization & delegationMedium
A nurse delegates the measurement of blood glucose to a trained assistant but never asks for the result. Which right of delegation is missing?
ARight task for the setting
BRight circumstance
CRight supervision and evaluation
DRight person for the task
6.Prioritization & delegationHard
A patient opens their eyes only to pain, uses inappropriate words and withdraws from pain. What is the Glasgow Coma Scale score?
A13
B7
C11
D9
7.Clinical nursingMedium
Why does a patient with a suspected TIA need urgent specialist assessment?
AThe symptoms will come back permanently within an hour
BThe patient needs urgent surgery on the brain
CThe risk of a full stroke is highest in the days after a TIA
DA TIA always turns into a brain tumour unless it is treated
8.Clinical nursingHard
A patient rescued from a house fire has soot around the mouth, singed nasal hairs and a hoarse voice. What is the main concern?
AAirway swelling from inhalation injury
BHypothermia from the fire service water
CDehydration from sweating
DA minor throat infection
9.Lab values & electrolytesMedium
A patient taking warfarin for atrial fibrillation has an INR of 5.2 and no bleeding. What is the nurse’s best action?
AAdvise the patient to stop eating green vegetables from today
BGive the usual dose and recheck in a month
CHold the warfarin dose and inform the prescriber
DGive a double dose
10.Lab values & electrolytesHard
The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?
A"My stools may look darker while I take the tablets"
B"I'll keep the tablets out of reach of the children"
C"I can take it with orange juice to help absorption"
D"I'll take my iron tablet with a big glass of milk"
11.PharmacologyMedium
Which lab tests are monitored in a patient taking carbamazepine?
ASerum amylase and lipase
BFull blood count and serum sodium
CThyroid antibodies and cortisol
DINR and aPTT
12.PharmacologyHard
A patient who uses insulin is taught sick-day rules. Which statement shows a need for further teaching?
A"I will keep drinking fluids, even if I cannot eat much."
B"I will check my blood glucose and ketones more often while I am ill."
C"If I am ill and not eating, I will stop my insulin completely."
D"I will seek help if I keep vomiting or have ketones."
13.Med-surg: cardiovascular & respiratoryMedium
Which pneumonia severity score uses confusion, urea, respiratory rate, blood pressure and age?
ANEWS2
BCHA₂DS₂-VASc
CWells score
DCURB-65
14.Med-surg: cardiovascular & respiratoryHard
A nurse teaches a patient who is starting warfarin. Which statement shows a need for further teaching?
A"I will have regular INR blood tests."
B"I will check before taking any new medicines or herbal remedies."
C"If I miss a dose, I will take two the next day."
D"I will tell my dentist that I take warfarin."
15.Med-surg: neuro, endocrine & renalMedium
Which approach helps most when talking to a patient with expressive aphasia?
AAvoid talking to them until their speech has recovered
BSpeak louder, because the patient cannot hear well
CAsk questions that can be answered with yes, no or a gesture
DFinish their sentences quickly to save them effort
16.Med-surg: neuro, endocrine & renalHard
After removal of a cortisol-producing adrenal adenoma, why may the patient need hydrocortisone for months?
AThe other adrenal gland has been suppressed
BThe tumour will grow back quickly without it
CThe operation always removes both adrenal glands
DHydrocortisone helps the wound to heal
17.Med-surg: GI, perioperative & oncologyMedium
Which measure helps reduce the risk of delirium in an older surgical patient?
AKeeping the room dark during the day
BMoving them to a new bed space each night to reduce boredom
CGiving a sleeping tablet every night
DMaking sure they have their glasses and hearing aids
18.Med-surg: GI, perioperative & oncologyHard
Four patients are on a gastroenterology ward. Which should the nurse see first?
AA patient with stable ulcerative colitis asking about diet
BA patient with cirrhosis who is newly confused and drowsy
CA patient with an ileostomy waiting to change the pouch
DA patient with GORD who wants an antacid
19.Maternity & obstetric nursingMedium
A baby has prolonged jaundice at 3 weeks with pale, chalky stools and dark urine. What should the nurse suspect?
ABiliary atresia
BPhysiological jaundice
CErythema toxicum
DBreast milk jaundice
20.Maternity & obstetric nursingHard
A term newborn has rapid breathing at 2 hours after a caesarean without labour. Saturation is normal, there is no fever and the chest X-ray shows fluid in the fissures. What is the most likely diagnosis?
ARespiratory distress syndrome of prematurity
BNeonatal pneumonia with sepsis
CMeconium aspiration syndrome
DTransient tachypnoea of the newborn
21.Pediatric nursingMedium
Which advice about screen use reflects common paediatric guidance for children under about 18 months?
ABackground TV helps language development
BAvoid screen media, apart from video calls with family
CScreens are fine as long as the volume is low
DUp to 2 hours a day of educational TV programmes is beneficial for language
22.Pediatric nursingHard
A 3-year-old was pulled from a pool after a brief submersion. She is now awake and coughs now and then. What should the nurse advise?
ATake her straight home, because she is awake, talking and only coughing now and then
BGive her a warm drink and put her to bed for a long sleep
CObserve her in hospital for several hours, as breathing problems can develop later
DOnly seek care if she develops a fever in the next week
23.Mental health nursingMedium
When should blood be taken to measure a patient's lithium level?
AAbout 12 hours after the last dose
BAt any time of day, since it makes no difference
CImmediately after the morning dose
D1 hour after the last dose
24.Mental health nursingHard
A behaviour plan states that staff will no longer give attention to a child's tantrums but will praise calm behaviour. For the first few days, the tantrums become worse. What does this most likely show?
AThat the tantrums are caused by a physical illness
BThat the plan has failed and should be stopped immediately
CThat the child needs firm punishment for each tantrum instead
DAn extinction burst, which is expected before the behaviour decreases
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 06:00 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
06:00
16:00 AM
28:00 AM
36:00 PM
45:00 AM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 21:25 and finishes at 00:45 the next morning (24-hour clock). How many minutes t did it run?
21:2500:45
t = min
27.Dosage calculationsMedium
A child weighing 8 kg is prescribed 20 mg/kg of a drug. The stock solution contains 40 mg/mL. Draw up the dose: what volume V do you give?
8 kg20 mg/kg40 mg/mL
V = mL
28.Dosage calculationsHard
An infusion contains 25000 units of a drug in 250 mL. The prescription is 2000 units per hour. At what rate R do you set the pump, in mL/h?
25000 units/250 mL2000 units/h
R = mL/h
29.IV infusion ratesMedium
1000 mL was ordered over 6 hours. After 3 hours you find that 610 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
1000 mL / 6 hafter 3 h: 610 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 250 mg of a drug in 100 mL and runs at 20 mL/h. How many milligrams per hour D does the patient receive?
250 mg/100 mL20 mL/h
D = mg/h
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 14 units/kg/h for a patient who weighs 96 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL14 units/kg/h96 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 2.5 mcg/kg/min for a patient who weighs 70 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
250 mg/250 mL2.5 mcg/kg/min70 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 78 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
78 kg12 hurine: 325 mLurine: 225 mLurine: 400 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 50 mL/h. At 20:00, 500 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL500 mL infused50 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient after a head injury does not open the eyes at all, makes only incomprehensible sounds such as moaning and shows as the best motor response: extension of the arms and legs (abnormal extension). Work out the GCS and classify the head injury by it. Click your answer.
1mild
2moderate
3severe
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: no; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: no; gait: weak; mental status: knows own limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 12 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 12 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
A practice gas shows pH 7.32, PaCO₂ 34 mmHg (4.5 kPa) and HCO₃⁻ 17 mmol/L, with Na⁺ 143 and Cl⁻ 92 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
Interpret this lead II rhythm strip. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1sinus tachycardia
2accelerated junctional rhythm
3supraventricular tachycardia (SVT)
4atrial fibrillation
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 · "Ate half of lunch; drank 200 mL of water."
Why this is the answer
Objective entries describe what was observed or measured. Vague or judgemental phrases such as "good" or "as usual" cannot be checked or compared.
Answer
B · "Ate half of lunch; drank 200 mL of water."
2.Nursing fundamentals
Answer: A · Refeeding syndrome with low phosphate, potassium and magnesium
Why this is the answer
When feeding restarts after starvation, insulin release drives phosphate, potassium and magnesium into the cells. Low levels can cause heart failure and arrhythmias, so feeding starts slowly and bloods are monitored.
Answer
A · Refeeding syndrome with low phosphate, potassium and magnesium
3.Infection control & patient safety
Answer: C · The field is considered contaminated and must be set up again
Why this is the answer
A sterile field must be kept in view at all times. If sterility cannot be confirmed, the field is treated as contaminated. The rule is: if in doubt, consider it non-sterile.
Answer
C · The field is considered contaminated and must be set up again
4.Infection control & patient safety
Answer: C · Using the more concentrated vial by mistake would give a tenfold overdose
Why this is the answer
Mix-ups between heparin strengths have caused deaths. The nurse checks the concentration on the label every time and uses an independent double check, and many hospitals limit which strengths are stocked.
Answer
C · Using the more concentrated vial by mistake would give a tenfold overdose
5.Prioritization & delegation
Answer: C · Right supervision and evaluation
Why this is the answer
The nurse must follow up, check the result and act on it. Delegating without checking the outcome breaks the right of supervision and evaluation.
Answer
C · Right supervision and evaluation
6.Prioritization & delegation
Answer: D · 9
Why this is the answer
Eyes open to pain scores 2, inappropriate words score 3 and withdrawal from pain scores 4, giving 9. A score of 8 or less often means the patient cannot protect their airway.
Answer
D · 9
7.Clinical nursing
Answer: C · The risk of a full stroke is highest in the days after a TIA
Why this is the answer
The risk of stroke is highest soon after a TIA. Rapid assessment and treatment, such as antiplatelets, statins and carotid imaging, reduce this risk.
Answer
C · The risk of a full stroke is highest in the days after a TIA
8.Clinical nursing
Answer: A · Airway swelling from inhalation injury
Why this is the answer
These signs suggest inhalation injury, which can cause rapid airway swelling and obstruction. Early senior anaesthetic review is needed, as early intubation may be required. Carbon monoxide poisoning must also be considered.
Answer
A · Airway swelling from inhalation injury
9.Lab values & electrolytes
Answer: C · Hold the warfarin dose and inform the prescriber
Why this is the answer
An INR of 5.2 is far above the target and increases the bleeding risk. The nurse holds the dose, checks for signs of bleeding and informs the prescriber, who may prescribe a lower dose or vitamin K.Checked against:Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024); Warfarin · MedlinePlus (NIH) (2026)
Answer
C · Hold the warfarin dose and inform the prescriber
10.Lab values & electrolytes
Answer: D · "I'll take my iron tablet with a big glass of milk"
Why this is the answer
Calcium in milk, as well as antacids and tea, reduces iron absorption, so iron should not be taken with them. Vitamin C improves absorption, dark stools are expected, and iron overdose is a serious poisoning risk in young children.Checked against:Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025); Iron in diet - Medical Encyclopedia · MedlinePlus (NIH) (2025)
Answer
D · "I'll take my iron tablet with a big glass of milk"
11.Pharmacology
Answer: B · Full blood count and serum sodium
Why this is the answer
Carbamazepine can rarely cause bone marrow suppression and commonly lowers serum sodium. Blood counts, sodium and liver tests are checked, especially early in treatment.
Answer
B · Full blood count and serum sodium
12.Pharmacology
Answer: C · "If I am ill and not eating, I will stop my insulin completely."
Why this is the answer
Stress hormones during illness often raise glucose, so basal insulin is usually continued and doses may need adjusting. Stopping insulin in type 1 diabetes can lead to ketoacidosis.
Answer
C · "If I am ill and not eating, I will stop my insulin completely."
13.Med-surg: cardiovascular & respiratory
Answer: D · CURB-65
Why this is the answer
CURB-65 gives one point each for Confusion, Urea >7 mmol/L, Respiratory rate ≥30/min, low Blood pressure (systolic <90 or diastolic ≤60 mmHg) and age ≥65. Higher scores mean higher mortality and the need for hospital or critical care.
Answer
D · CURB-65
14.Med-surg: cardiovascular & respiratory
Answer: C · "If I miss a dose, I will take two the next day."
Why this is the answer
Doubling up after a missed dose can cause over-anticoagulation and bleeding. Patients are usually told to take a missed dose the same day if they remember, or skip it and record it, then seek advice. Regular INR checks, telling other clinicians and checking interactions are correct.
Answer
C · "If I miss a dose, I will take two the next day."
15.Med-surg: neuro, endocrine & renal
Answer: C · Ask questions that can be answered with yes, no or a gesture
Why this is the answer
In expressive aphasia, comprehension is largely preserved. Short, closed questions, extra time, gestures and picture or word boards help. Shouting does not help, and constantly finishing sentences can frustrate the patient.
Answer
C · Ask questions that can be answered with yes, no or a gesture
16.Med-surg: neuro, endocrine & renal
Answer: A · The other adrenal gland has been suppressed
Why this is the answer
Excess cortisol from the adenoma suppressed ACTH, so the remaining adrenal gland is shrunken and underactive. Steroid replacement is needed until it recovers, which can take months. Stopping too early risks adrenal crisis.
Answer
A · The other adrenal gland has been suppressed
17.Med-surg: GI, perioperative & oncology
Answer: D · Making sure they have their glasses and hearing aids
Why this is the answer
Delirium prevention includes using glasses and hearing aids, orientation, good sleep, hydration, nutrition, early mobilisation, pain control, avoiding unnecessary sedatives and involving family.
Answer
D · Making sure they have their glasses and hearing aids
18.Med-surg: GI, perioperative & oncology
Answer: B · A patient with cirrhosis who is newly confused and drowsy
Why this is the answer
New confusion and drowsiness in cirrhosis may be hepatic encephalopathy with a precipitant such as bleeding or infection, and the airway may be at risk. The others are stable.
Answer
B · A patient with cirrhosis who is newly confused and drowsy
19.Maternity & obstetric nursing
Answer: A · Biliary atresia
Why this is the answer
Pale stools and dark urine point to conjugated (obstructive) jaundice, such as biliary atresia. Early surgery gives the best outcome, so this needs urgent referral.
Answer
A · Biliary atresia
20.Maternity & obstetric nursing
Answer: D · Transient tachypnoea of the newborn
Why this is the answer
Transient tachypnoea is common after caesarean birth without labour. Supportive care is usually enough, but infection must be considered if the baby becomes unwell or fails to improve.
Answer
D · Transient tachypnoea of the newborn
21.Pediatric nursing
Answer: B · Avoid screen media, apart from video calls with family
Why this is the answer
Young children learn through face-to-face interaction and play. Guidance such as the American Academy of Pediatrics advises avoiding screens other than video chatting under about 18–24 months, and limited, shared, high-quality viewing after that.
Answer
B · Avoid screen media, apart from video calls with family
22.Pediatric nursing
Answer: C · Observe her in hospital for several hours, as breathing problems can develop later
Why this is the answer
After a drowning incident, even a child who seems well can develop worsening breathing difficulty and low oxygen over the following hours. Children who had symptoms such as coughing need medical assessment and a period of observation.
Answer
C · Observe her in hospital for several hours, as breathing problems can develop later
23.Mental health nursing
Answer: A · About 12 hours after the last dose
Why this is the answer
Lithium levels are drawn about 12 hours after the last dose, usually in the morning before the next dose, so results can be compared with the target range.
Answer
A · About 12 hours after the last dose
24.Mental health nursing
Answer: D · An extinction burst, which is expected before the behaviour decreases
Why this is the answer
When a reinforced behaviour stops being rewarded, it often increases temporarily (an extinction burst) before declining. Consistency by all staff is essential, while safety is always maintained.
Answer
D · An extinction burst, which is expected before the behaviour decreases
25.Nursing math & unit conversions
Answer: 6:00 AM
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Convert the hour
06 → 6 AM
Answer
6:00 AM
Answer
6:00 AM
26.Nursing math & unit conversions
Answer: t = 200 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
21:25 → 24:00 = 155 min
After midnight
00:00 → 00:45 = 45 min
Total
t = 155 + 45 = 200 min
Answer
t = 200 min
27.Dosage calculations
Answer: V = 4 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 = 20·8 = 160 mg
Volume
V = 160/40 = 4 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4 mL
28.Dosage calculations
Answer: R = 20 mL/h
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration
25000/250 = 100 units/mL
Pump rate
R = 2000/100 = 20 mL/h
Answer
R = 20 mL/h
29.IV infusion rates
Answer: R = 203.3 mL/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
1000/6 = 166.7 mL/h
New rate
R = 610/3 = 203.3 mL/h
Answer
R = 203.3 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: D = 50 mg/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Concentration
250/100 = 2.5 mg/mL
Dose rate
D = 2.5·20 = 50 mg/h
Answer
D = 50 mg/h
31.Pediatric & critical-care dosing
Answer: R = 33.6 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
14·96 = 1 344 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1344/40 = 33.6 mL/h
Answer
R = 33.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 10.5 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
2.5·70 = 175 mcg/min
175·60 = 10500 mcg/h
Pump rate
R = 10500/1000 = 10.5 mL/h
Answer
R = 10.5 mL/h
33.IV fluids & fluid balance
Answer: U = 1.01 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
325 + 225 + 400 = 950 mL
Per kilogram per hour
U = 950/(78·12) = 1.015 ≈ 1.01 mL/kg/h
Answer
U = 1.01 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 10 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 − 500 = 500 mL
Time
t = 500/50 = 10 h
Answer
t = 10 h
That is about 10 h 00 min, so the bag runs out at about 06:00.
35.Clinical assessment scores
Answer: severe
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.
Score each area
E: does not open the eyes at all → 1
V: makes only incomprehensible sounds such as moaning → 2
M: extension of the arms and legs (abnormal extension) → 2
Add
GCS = 1 + 2 + 2 = 5
Severity
GCS 5 → severe
Answer
severe
36.Clinical assessment scores
Answer: low risk
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: no → 0
secondary diagnosis: no → 0
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: no → 0
gait: weak → 10
mental status: knows own limits → 0
Add
Morse total = 0 + 0 + 0 + 0 + 10 + 0 = 10
Risk level
10 → low risk
Answer
low risk
37.Arterial blood gas interpretation
Answer: PaCO₂ = 26 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.
Winter’s formula
PaCO₂ = 1.5·12 + 8 = 26 mmHg
range: 24–28 mmHg
Answer
PaCO₂ = 26 mmHg
38.Arterial blood gas interpretation
Answer: added metabolic alkalosis
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.
Anion gap
AG = 143 − (92 + 17) = 34
Delta ratio
(34 − 12)/(24 − 17) = 3.143
added metabolic alkalosis
Answer
added metabolic alkalosis
39.ECG rhythm strip interpretation
Answer: supraventricular tachycardia (SVT)
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC. 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).
Five steps
1. Rate: R–R = 10 small boxes, 1500 ÷ 10 ≈ 150 per minute.
2. Rhythm: regular, every R–R is 0.40 s.
3. P waves: none visible; at this rate they are hidden in the QRS complexes or the T waves.
4. PR interval: not measurable.
5. QRS: 0.06 s, narrow (below 0.12 s), so the rhythm starts above the ventricles.
Interpretation
supraventricular tachycardia (SVT)
Answer
supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretation
Answer: ventricular rate = 50 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 = 18 small boxes = 0.72 s → 1500 ÷ 18 = 83.33 ≈ 83 per minute
Ventricular rate
R–R = 30 small boxes = 1.20 s → 1500 ÷ 30 = 50 ≈ 50 per minute
Answer
ventricular rate = 50 bpm
Answer
ventricular rate = 50 bpm
Third-degree block with a narrow-complex junctional escape (usually 40–60 per minute).
This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.