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 measures help prevent constipation in hospital patients?
AAvoiding fruit and vegetables
BLimiting fluids and staying in bed to rest the bowel
CHolding in the urge to open the bowels
DAdequate fluids, dietary fibre and mobility
2.Nursing fundamentalsHard
A nurse realises that a dose of analgesia given two hours ago was not documented. What is correct?
ALeave it out, as it is now too late to record it in the notes
BWrite it now as a late entry, stating when it was given
CWrite it in the space for two hours ago as if it was recorded then
DAsk a colleague to sign that they gave it
3.Infection control & patient safetyMedium
When is a prophylactic antibiotic usually given to prevent a surgical site infection?
AThe day after surgery, once the wound is closed
BOne week before surgery
CWithin about 60 minutes before the incision
DOnly if a fever develops after surgery
4.Infection control & patient safetyHard
A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?
AYes, near misses are reported so system weaknesses can be fixed
BOnly if the same error happens three times
CNo, because the patient was not harmed
DNo, because reporting near misses only blames the pharmacy staff for nothing
5.Prioritization & delegationMedium
A patient has taken prednisone (prednisolone in many countries) for several months. Which statement shows a need for further teaching?
A“I will stop the tablets as soon as I feel better.”
B“I will tell my dentist and other doctors that I take a steroid.”
C“I will report signs of infection early.”
D“I will take the tablets with food.”
6.Prioritization & delegationHard
During surgery under general anesthesia, a patient develops rising end-tidal carbon dioxide, muscle rigidity and a rapidly increasing temperature. Which drug should the nurse anticipate?
AFlumazenil
BNaloxone
CDantrolene
DAtropine
7.Clinical nursingMedium
Which group of symptoms suggests hypercalcaemia?
AThirst, constipation, confusion and abdominal pain
BSweating, tremor and sudden hunger
CWeight gain, feeling cold and a slow pulse
DTingling lips, muscle cramps and spasms of the hands and feet
8.Clinical nursingHard
A nurse teaches a patient with asthma about a new inhaled steroid "preventer". Which statement shows a need for further teaching?
A"I will rinse my mouth after using it."
B"I'll keep my reliever inhaler with me."
C"I will use it every day even when I feel well."
D"I will only use it when I'm wheezy."
9.Lab values & electrolytesMedium
A patient with acute pancreatitis has muscle twitching and numbness around the mouth. Which laboratory value should the nurse check?
ASerum chloride
BSerum calcium
CSerum sodium
DSerum amylase
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"I can take it with orange juice to help absorption"
B"I'll take my iron tablet with a big glass of milk"
C"I'll keep the tablets out of reach of the children"
D"My stools may look darker while I take the tablets"
11.PharmacologyMedium
Which approach is usually recommended to prevent constipation in a patient on regular opioids?
ANo laxative until the patient has not opened the bowels for a week
BA stimulant laxative such as senna, often with a stool softener
CBulk-forming fibre alone, with fluid intake restricted
DAn antidiarrhoeal drug at night to slow the gut
12.PharmacologyHard
Why do infants absorb more of a topical corticosteroid than adults?
ATheir liver changes the cream into a much stronger form
BThey have more skin area per kilogram and thinner skin
CInfants do not absorb topical drugs at all
DTheir skin contains no blood vessels
13.Med-surg: cardiovascular & respiratoryMedium
A patient with heart failure takes furosemide once a day. When is the best time to take it?
AWhenever the ankles look swollen, on those days only
BAt bedtime, so the effect lasts through the night
CIn the morning, to avoid needing the toilet at night
DJust before the evening meal, with a large drink
14.Med-surg: cardiovascular & respiratoryHard
A patient recovering from an MI is anxious about returning to normal life. Which intervention best supports recovery?
AAdvice to stop tablets once they feel well
BReferral to cardiac rehabilitation
CAdvice to rest in bed for three months
DAdvice to avoid all exercise permanently
15.Med-surg: neuro, endocrine & renalMedium
How should peritoneal dialysis fluid be warmed before use?
AIn a microwave oven
BIn a dedicated dry-heat warmer
CIn a bowl of hot tap water
DIt should be used cold from the fridge
16.Med-surg: neuro, endocrine & renalHard
Two days after a C5 spinal cord injury, a patient is anxious, with a respiratory rate of 30/min and a falling vital capacity. What should the nurse do?
ALie the patient flat with the head tilted back to open the airway
BRecheck the vital capacity again in about 12 hours
CGive a sedative to slow the breathing and ease the anxiety
DEscalate urgently: cord oedema may cause respiratory failure
17.Med-surg: GI, perioperative & oncologyMedium
Why is thiamine given to patients with alcohol dependence admitted to hospital?
ATo treat the cirrhosis directly
BTo prevent Wernicke's encephalopathy
CTo prevent bleeding from varices
DTo reduce the craving for alcohol
18.Med-surg: GI, perioperative & oncologyHard
A patient has sharp, tearing pain on passing stool, "like passing glass", with a streak of fresh blood. Which condition is most likely?
AAnal fissure
BCrohn's disease of the ileum
CUpper GI bleeding
DColorectal cancer
19.Maternity & obstetric nursingMedium
A woman in labour has severe back pain with each contraction. The fetus is in an occiput posterior position. Which measure is most likely to help?
ALying flat on her back with her legs raised
BHolding her breath and pushing with each contraction
CSacral counterpressure and a hands-and-knees position
DAvoiding movement until full dilation
20.Maternity & obstetric nursingHard
The triage nurse receives four phone calls from pregnant women. Who should be told to come in immediately?
AAt 30 weeks with heartburn after large meals
BAt 25 weeks with mild backache after standing
CAt 12 weeks with mild nausea in the mornings
DAt 36 weeks with constant pain and a hard uterus
21.Pediatric nursingMedium
Which medicine may be used to close a patent ductus arteriosus in a preterm baby?
AIbuprofen or indomethacin
BSalbutamol
CProstaglandin E1
DIntravenous furosemide infusion
22.Pediatric nursingHard
A child has a swollen, red eyelid with fever, pain on moving the eye and blurred vision. What should the nurse suspect?
AOrbital cellulitis, which needs urgent review and IV antibiotics
BA stye, which will drain on its own with warm compresses
CAn insect bite, which needs only a cold compress
DSimple conjunctivitis, treated with eye drops at home
23.Mental health nursingMedium
A patient has taken a benzodiazepine daily for many months. Why must it not be stopped abruptly?
AThere is no risk; benzodiazepines can be stopped at any time without tapering
BIt would cause immediate weight gain
CSudden withdrawal can cause severe anxiety, insomnia and seizures
DThe patient would become allergic to it
24.Mental health nursingHard
A patient with PTSD suddenly appears terrified, staring and breathing quickly, and says she is "back there". What should the nurse do first?
ALeave the room so she can calm down alone
BAsk her to describe every detail of the trauma straight away so that she can process the memory
CTouch her suddenly from behind to get her attention
DSpeak calmly, use her name and use grounding techniques to bring her attention to the present
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 37.5 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
37.5 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 17:15 and finishes at 02:50 the next morning (24-hour clock). How many minutes t did it run?
17:1502:50
t = min
27.Dosage calculationsMedium
A child weighing 22 kg is prescribed 2 mg/kg of a drug. The stock solution contains 20 mg/mL. Draw up the dose: what volume V do you give?
22 kg2 mg/kg20 mg/mL
V = mL
28.Dosage calculationsHard
A patient is 112 cm tall and weighs 24 kg. The prescription is 100 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
112 cm24 kg100 mg/m²
D = mg
29.IV infusion ratesMedium
An infusion is ordered at 40 mL/h, but no pump is available. It runs by gravity through a giving set of 15 gtt/mL. Find the drip rate R in drops per minute.
40 mL/h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 100 mg in 250 mL runs at 20 mL/h. How many micrograms per minute D does the patient receive?
100 mg/250 mL20 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 500 mL. The order is 16 units/kg/h for a patient who weighs 103 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL16 units/kg/h103 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 57 kg has an order for norepinephrine at 4 mcg/min. The bag contains 8 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
8 mg/250 mL4 mcg/min57 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL. Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 19:00 at 100 mL/h. After 3 hours the rate is changed to 60 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL100 mL/h · 3 h60 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: yes; ambulatory aid: holds on to furniture; IV therapy or saline lock: no; gait: weak; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 93 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 65 mmHg?
MAP 65 mmHgSBP 93 mmHg
DBP = mmHg
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 a metabolic alkalosis with HCO₃⁻ 32 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 32 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
This lead II strip shows atrial flutter. How many flutter waves per QRS complex are there (the n of n:1 conduction)?
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
flutter waves per QRS =
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1third-degree (complete) AV block
2ventricular paced rhythm
3dual-chamber (AV) paced rhythm
4sinus rhythm with wide QRS
3Solutions
1.Nursing fundamentals
Answer: D · Adequate fluids, dietary fibre and mobility
Why this is the answer
Fluids and fibre soften stools, and activity stimulates gut movement. Privacy and responding to the urge to defecate also help. Opioids and immobility increase the risk.
Answer
D · Adequate fluids, dietary fibre and mobility
2.Nursing fundamentals
Answer: B · Write it now as a late entry, stating when it was given
Why this is the answer
Late entries are clearly marked as such, showing both when care was given and when the note was written. This keeps the record accurate and prevents a second dose being given.
Answer
B · Write it now as a late entry, stating when it was given
3.Infection control & patient safety
Answer: C · Within about 60 minutes before the incision
Why this is the answer
For most drugs, prophylaxis is given within 60 minutes before the incision so tissue levels are high during surgery. Some drugs, such as vancomycin, start earlier because they are infused over longer.
Answer
C · Within about 60 minutes before the incision
4.Infection control & patient safety
Answer: A · Yes, near misses are reported so system weaknesses can be fixed
Why this is the answer
Near misses show where errors can slip through and are reported in the same way as errors that reach the patient. Learning from them prevents future harm.
Answer
A · Yes, near misses are reported so system weaknesses can be fixed
5.Prioritization & delegation
Answer: A · “I will stop the tablets as soon as I feel better.”
Why this is the answer
Stopping long-term corticosteroids suddenly can cause adrenal crisis, so they are tapered as prescribed. Taking them with food, telling other prescribers and reporting infection are correct.
Answer
A · “I will stop the tablets as soon as I feel better.”
6.Prioritization & delegation
Answer: C · Dantrolene
Why this is the answer
Malignant hyperthermia is a reaction to some anesthetic agents that causes hypermetabolism. The triggering drug is stopped and dantrolene is given, with active cooling and support.
Answer
C · Dantrolene
7.Clinical nursing
Answer: A · Thirst, constipation, confusion and abdominal pain
Why this is the answer
High calcium causes polyuria and thirst, constipation, abdominal pain, kidney stones and confusion. Tingling and cramps suggest low calcium instead.
Answer
A · Thirst, constipation, confusion and abdominal pain
8.Clinical nursing
Answer: D · "I will only use it when I'm wheezy."
Why this is the answer
Inhaled corticosteroids must be used regularly to reduce airway inflammation and prevent attacks. The short-acting reliever is used for symptoms.
Answer
D · "I will only use it when I'm wheezy."
9.Lab values & electrolytes
Answer: B · Serum calcium
Why this is the answer
In severe pancreatitis, fatty acids released from damaged fat bind calcium (saponification), causing hypocalcemia. Twitching and perioral numbness are signs of low calcium, which can progress to tetany and seizures.
Answer
B · Serum calcium
10.Lab values & electrolytes
Answer: B · "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.
Answer
B · "I'll take my iron tablet with a big glass of milk"
11.Pharmacology
Answer: B · A stimulant laxative such as senna, often with a stool softener
Why this is the answer
Opioid-induced constipation does not usually resolve with time, so a laxative is started with the opioid. Stimulant laxatives counter reduced motility; bulk-forming laxatives alone can worsen symptoms if fluid intake is low.
Answer
B · A stimulant laxative such as senna, often with a stool softener
12.Pharmacology
Answer: B · They have more skin area per kilogram and thinner skin
Why this is the answer
Infants have a high surface area-to-weight ratio and a thinner skin barrier, so topical drugs reach higher systemic levels. Nappies can act as an occlusive dressing and increase absorption further.
Answer
B · They have more skin area per kilogram and thinner skin
13.Med-surg: cardiovascular & respiratory
Answer: C · In the morning, to avoid needing the toilet at night
Why this is the answer
Loop diuretics produce a brisk diuresis that lasts several hours. Taking them in the morning (and a second dose by early afternoon if prescribed) avoids nocturia, broken sleep and night-time falls.
Answer
C · In the morning, to avoid needing the toilet at night
14.Med-surg: cardiovascular & respiratory
Answer: B · Referral to cardiac rehabilitation
Why this is the answer
Cardiac rehabilitation combines supervised exercise, risk factor education, medication advice and psychological support. It improves quality of life and reduces cardiovascular mortality and readmissions. Patients are encouraged to return gradually to activity, including work, driving and sex, according to advice.
Answer
B · Referral to cardiac rehabilitation
15.Med-surg: neuro, endocrine & renal
Answer: B · In a dedicated dry-heat warmer
Why this is the answer
Warming dialysate to body temperature improves comfort. A microwave heats unevenly and can create hot spots; soaking can contaminate the ports. Manufacturer-approved dry heat warmers are used.
Answer
B · In a dedicated dry-heat warmer
16.Med-surg: neuro, endocrine & renal
Answer: D · Escalate urgently: cord oedema may cause respiratory failure
Why this is the answer
Cord oedema in the days after a cervical injury can extend to C3–C5, weakening the diaphragm. A falling vital capacity, rising respiratory rate and anxiety signal impending respiratory failure, and early critical care input is needed. Sedation would depress breathing further.
Answer
D · Escalate urgently: cord oedema may cause respiratory failure
17.Med-surg: GI, perioperative & oncology
Answer: B · To prevent Wernicke's encephalopathy
Why this is the answer
Thiamine deficiency is common in alcohol dependence and can cause Wernicke's encephalopathy (confusion, ataxia, eye signs). Thiamine is given early, ideally before or with glucose, as glucose can worsen deficiency.
Answer
B · To prevent Wernicke's encephalopathy
18.Med-surg: GI, perioperative & oncology
Answer: A · Anal fissure
Why this is the answer
An anal fissure causes severe pain during and after defecation with bright red blood. Treatment includes stool softeners, fibre and topical treatment to relax the sphincter.
Answer
A · Anal fissure
19.Maternity & obstetric nursing
Answer: C · Sacral counterpressure and a hands-and-knees position
Why this is the answer
In occiput posterior positions the fetal head presses on the sacrum. Counterpressure on the lower back and positions such as hands-and-knees or leaning forward ease pain and may help the head rotate.
Answer
C · Sacral counterpressure and a hands-and-knees position
20.Maternity & obstetric nursing
Answer: D · At 36 weeks with constant pain and a hard uterus
Why this is the answer
Constant pain with a hard, tender uterus suggests placental abruption, which can threaten mother and fetus even with little visible bleeding. The other symptoms are common discomforts.
Answer
D · At 36 weeks with constant pain and a hard uterus
21.Pediatric nursing
Answer: A · Ibuprofen or indomethacin
Why this is the answer
Indomethacin and ibuprofen inhibit prostaglandin production and can close a patent duct in preterm infants; paracetamol is also used in some units. Prostaglandin E1 does the opposite and keeps the duct open.
Answer
A · Ibuprofen or indomethacin
22.Pediatric nursing
Answer: A · Orbital cellulitis, which needs urgent review and IV antibiotics
Why this is the answer
Painful eye movements, reduced vision or proptosis with eyelid swelling suggest orbital cellulitis, which can spread to the brain. The child needs urgent assessment, imaging if indicated and IV antibiotics.
Answer
A · Orbital cellulitis, which needs urgent review and IV antibiotics
23.Mental health nursing
Answer: C · Sudden withdrawal can cause severe anxiety, insomnia and seizures
Why this is the answer
Long-term benzodiazepine use causes physical dependence. Abrupt discontinuation can cause rebound anxiety, tremor and seizures, so the dose is tapered gradually.
Answer
C · Sudden withdrawal can cause severe anxiety, insomnia and seizures
24.Mental health nursing
Answer: D · Speak calmly, use her name and use grounding techniques to bring her attention to the present
Why this is the answer
During a flashback, grounding (orienting to the present, using the senses, calm reassurance) helps the patient regain contact with reality. Detailed trauma work belongs in planned therapy, and sudden touch can be frightening.
Answer
D · Speak calmly, use her name and use grounding techniques to bring her attention to the present
25.Nursing math & unit conversions
Answer: T = 99.5 °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
37.5·9/5 = 67.5
Add 32
T = 67.5 + 32 = 99.5 °F
Answer
T = 99.5 °F
26.Nursing math & unit conversions
Answer: t = 575 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
17:15 → 24:00 = 405 min
After midnight
00:00 → 02:50 = 170 min
Total
t = 405 + 170 = 575 min
Answer
t = 575 min
27.Dosage calculations
Answer: V = 2.2 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 = 2·22 = 44 mg
Volume
V = 44/20 = 2.2 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 2.2 mL
28.Dosage calculations
Answer: D = 86.41 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
Body surface area
BSA = √(112·24/3600) = √0.7467 = 0.8641 m²
Dose
D = 100·0.8641 = 86.41 mg
Answer
D = 86.41 mg
29.IV infusion rates
Answer: R = 10 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Millilitres per minute
40/60 = 0.6667 mL/min
Drip rate
R = 0.6667·15 = 10 gtt/min
Answer
R = 10 gtt/min
30.IV infusion rates
Answer: D = 133.3 mcg/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
100000 mcg/250 mL = 400 mcg/mL
Dose per hour
20·400 = 8000 mcg/h
Dose per minute
D = 8000/60 = 133.3 mcg/min
Answer
D = 133.3 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 33 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
16·103 = 1 648 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 1648/50 = 32.96 ≈ 33 mL/h
Answer
R = 33 mL/h
32.Pediatric & critical-care dosing
Answer: R = 7.5 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
8 000/250 = 32 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
4·60 = 240 mcg/h
Pump rate
R = 240/32 = 7.5 mL/h
Answer
R = 7.5 mL/h
33.IV fluids & fluid balance
Answer: I = 1030 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: 150 + 100 + 180 = 430 mL
ice chips: 200/2 = 100 mL
IV infusion: 50·8 = 400 mL
IV antibiotic: 2·50 = 100 mL
I = 1030 mL
Answer
I = 1030 mL
34.IV fluids & fluid balance
Answer: t = 6.3 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
100·3 = 300 mL
500 − 300 = 200 mL left
Second part
200/60 = 3.333 h
Total time
t = 3 + 3.333 = 6.333 ≈ 6.3 h
Answer
t = 6.3 h
That is about 6 h 20 min, so the bag runs out at about 01:20.
35.Clinical assessment scores
Answer: MFS = 55
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: yes → 15
ambulatory aid: holds on to furniture → 30
IV therapy or saline lock: no → 0
gait: weak → 10
mental status: knows own limits → 0
Add
Morse total = 0 + 15 + 30 + 0 + 10 + 0 = 55
Answer
MFS = 55
36.Clinical assessment scores
Answer: DBP = 51 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·65 − 93)/2 = 102/2 = 51 mmHg
Answer
DBP = 51 mmHg
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: PaCO₂ = 43.4 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
0.7·32 + 21 = 43.4 mmHg
Answer
PaCO₂ = 43.4 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: flutter waves per QRS = 2
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.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 10 small boxes = 0.40 s → 1500 ÷ 10 = 150 per minute
conduction ratio = 300 ÷ 150 = 2:1
Answer
flutter waves per QRS = 2
40.ECG rhythm strip interpretation
Answer: ventricular paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 22 small boxes, 1500 ÷ 22 ≈ 68 per minute.
2. Rhythm: regular, every R–R is 0.88 s.
3. P waves: none visible; a sharp pacing spike comes just before every QRS.
4. PR interval: not measurable.
5. QRS: 0.16 s, wide, and every spike is followed by a QRS (capture).
Interpretation
ventricular paced rhythm
Answer
ventricular paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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