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
When is a sputum sample for culture best collected?
AIn the evening, after the patient has eaten and drunk
BAt any time, using saliva from the mouth
CIn the morning, from a deep cough, before antibiotics start
DAfter the first few doses of antibiotics
2.Nursing fundamentalsHard
A patient with suspected pulmonary tuberculosis has to go to the X-ray department. What is correct?
AThe patient wears a surgical mask during transport
BThe patient cannot leave the room under any circumstances
CNo precautions are needed outside the ward
DThe patient wears a respirator and staff wear nothing
3.Infection control & patient safetyMedium
Which cleaning product is recommended for the room of a patient with Clostridioides difficile?
APlain water and a clean microfiber cloth
BA sporicidal agent, such as a chlorine-based solution
CA scented air freshener spray
DAlcohol-based wipes, used on every surface twice a day
4.Infection control & patient safetyHard
Two look-alike vials of different drugs are stored next to each other, and a nurse almost picks the wrong one. Which response best reflects a just culture?
AReport it and fix the system, for example by separating the vials
BTell the nurse to be more careful and do nothing else
CDiscipline the nurse who nearly picked the wrong vial
DKeep the incident quiet to protect the unit’s reputation
5.Prioritization & delegationMedium
An older adult asks for something to help them sleep. Which drug is most likely to cause confusion and falls in this age group?
ADiphenhydramine
BA warm milky drink
CMelatonin
DAcetaminophen (paracetamol)
6.Prioritization & delegationHard
A patient has a potassium of 7.0 mEq/L with peaked T waves. Several drugs are prescribed. Which one is usually given first to protect the heart?
AOral sodium bicarbonate
BOral potassium binder
CIV calcium gluconate
DIV furosemide
7.Clinical nursingMedium
In UK guidance, neutropenic sepsis is commonly defined by a temperature above 38 °C or signs of sepsis with a neutrophil count at or below:
A15 × 109/L
B5 × 109/L
C150 × 109/L
D0.5 × 109/L
8.Clinical nursingHard
A patient with acute pancreatitis is in severe epigastric pain radiating to the back. Which nursing care is most important?
AAdequate pain relief, IV fluids and close fluid balance monitoring
BA large fatty meal to stimulate the pancreas
CStrict bed rest without observations
DRestricting all fluids
9.Lab values & electrolytesMedium
A patient with type 2 diabetes has a target HbA1c below 7% (53 mmol/mol). Today's result is 7.8% (62 mmol/mol). What is the best interpretation?
AAverage glucose over the past months has been above the target
BThe result shows today's fasting glucose is above the target
CThe patient has had frequent episodes of severe hypoglycemia
DGlucose control has been excellent for the past several months
10.Lab values & electrolytesHard
A patient on digoxin has a calcium of 12.1 mg/dL (3.0 mmol/L) and new nausea and a slow pulse. Why is the calcium result important?
AHigh calcium blocks digoxin, so the drug stops working
BHigh calcium increases the risk of digoxin toxicity
CHigh calcium makes the kidneys clear digoxin faster
DHigh calcium only matters if the potassium is also high
11.PharmacologyMedium
During an amphotericin B infusion, the patient has fever, chills and shaking. What is the most likely explanation?
AA sign that the fungal infection is cured
BA sign that the drug has been given into an artery
CSevere hypoglycaemia caused by the drug
DA common infusion reaction to amphotericin B
12.PharmacologyHard
A patient receiving frequent salbutamol (albuterol) nebulisers develops a fine tremor and a heart rate of 120 per minute. What is the best explanation?
ASalbutamol causes high potassium, which speeds the heart and causes muscle twitching
BThe patient is allergic to salbutamol and needs adrenaline
CSalbutamol blocks muscarinic receptors in the heart
DAt high doses it also stimulates beta receptors in skeletal muscle and the heart
13.Med-surg: cardiovascular & respiratoryMedium
A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?
AOnly the pulse rate will be affected
BThe reading will be falsely low
CThe reading will be falsely high
DThe reading will be accurate but slower
14.Med-surg: cardiovascular & respiratoryHard
Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?
ALow blood glucose from fasting
BAn allergic reaction to the commode
CA vagal response to straining
DA new pulmonary embolism
15.Med-surg: neuro, endocrine & renalMedium
A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?
AAvoiding large meals late in the evening
BRaising the head of the bed at night
CMagnesium-containing antacids
DEating smaller, more frequent meals
16.Med-surg: neuro, endocrine & renalHard
A patient with CKD has a high phosphate, a low calcium and a high PTH. What does this show?
AToo much vitamin D from supplements
BPrimary hyperparathyroidism from a tumour
CSecondary hyperparathyroidism from CKD
DHypoparathyroidism after neck surgery
17.Med-surg: GI, perioperative & oncologyMedium
Which initial treatment is usual for symptomatic hypercalcaemia of malignancy?
AOral calcium tablets and vitamin D
BA high-calcium diet with extra milk
CFluid restriction and a thiazide diuretic
DIV fluids followed by an IV bisphosphonate
18.Med-surg: GI, perioperative & oncologyHard
After a fall, a patient with advanced dementia is agitated, grimacing and guarding the hip, and cannot rate the pain. What should the nurse do?
AAssume there is no pain because none is reported
BWait until a relative can confirm the pain
CGive a sedative to treat the agitation and avoid giving any analgesia
DUse an observational pain tool, give analgesia and reassess
19.Maternity & obstetric nursingMedium
Why is it important that the uterus relaxes fully between contractions?
AIt reduces the mother's need for fluids
BIt allows the cervix to close again between contractions
CIt prevents the membranes from rupturing
DBlood flow to the placenta is restored between contractions
20.Maternity & obstetric nursingHard
Monochorionic twins at 22 weeks show one twin with polyhydramnios and a large bladder and the other with almost no fluid. What condition is suspected?
ATwin-to-twin transfusion syndrome
BRh isoimmunisation
CGestational diabetes in one twin
DPlacenta praevia
21.Pediatric nursingMedium
The parents of a 2-year-old worry that she eats much less than she did as a baby. She is growing along her centile. What should the nurse advise?
AThis is a sign of illness and she needs blood tests
BEncourage her to finish every meal, even if this takes a long time at the table
CAppetite falls as growth slows; offer small, healthy portions without pressure
DGive extra bottles of milk to make up for the meals she refuses
22.Pediatric nursingHard
A 7-year-old with an asthma attack was wheezing loudly but is now quiet, drowsy and has very reduced air entry. What does this indicate?
AA good response to the reliever inhaler, with the airways now opening up again
BA life-threatening deterioration with exhaustion and very poor air movement
CThe child is falling asleep normally
DThe attack is resolving
23.Mental health nursingMedium
Which preparation is usual before electroconvulsive therapy (ECT)?
AStopping all regular medicines for 2 weeks before the first treatment
BEating a large meal to prevent low blood sugar during the seizure
CNo preparation, because the patient stays fully awake during ECT
DFasting for several hours, because a brief general anaesthetic is given
24.Mental health nursingHard
A patient with an anxiety disorder speaks so quickly about her worries that the nurse cannot follow. Which response is most helpful?
A"There's really nothing to worry about, so just try to relax."
B"Let's slow down and talk about one thing at a time. What worries you most right now?"
C"Let me tell you what I think your problem is, and then we can talk."
D"You're talking too fast, so we'll have to stop for today."
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 38.2 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
38.2 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 6 fl oz of juice, ½ tsp of cough syrup, 3 tbsp of liquid supplement. Using the equivalents given, find the total oral intake V in mL.
1 fl oz = 30 mL1 tsp = 5 mL1 tbsp = 15 mL
V = mL
27.Dosage calculationsMedium
A vial contains 2 g of powder. The label says: add 7.4 mL of water for injection to give a total volume of 8 mL. The prescription is 750 mg. What volume V of the reconstituted solution do you give?
2 g+ 7.4 mL → 8 mL750 mg
V = mL
28.Dosage calculationsHard
The prescription is 1500 units of a drug that comes as 5000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
1500 units5000 units/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 30 gtt/min through a set of 60 gtt/mL. How many millilitres V does the patient receive in 3 hours?
30 gtt/min60 gtt/mL3 h
V = mL
30.IV infusion ratesHard
A bag contains 1 g of a drug in 500 mL. The order is 0.5 mg per minute. At what rate R do you set the pump, in mL/h?
1 g/500 mL0.5 mg/min
R = mL/h
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 15 units/kg/h for a patient who weighs 92 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/500 mL15 units/kg/h92 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 800 mg in 500 mL. The order is 6 mcg/kg/min for a patient who weighs 58 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL6 mcg/kg/min58 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 patient weighs 57 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
57 kg8 hurine: 325 mLurine: 300 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 16:00 at 80 mL/h. After 3 hours the rate is changed to 75 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 mL80 mL/h · 3 h75 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: yes; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: yes; gait: impaired; 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). An adult weighs 118 kg and is 186 cm tall. Calculate the BMI and click the WHO weight category.
118 kg186 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.44, PaCO₂ 23 mmHg (3.1 kPa) and HCO₃⁻ 15 mmol/L. The primary disorder is respiratory alkalosis. How far is it compensated? Click your answer.
pH 7.44PaCO₂ 23 mmHg (3.1 kPa)HCO₃⁻ 15 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows pH 7.32, PaCO₂ 32 mmHg (4.3 kPa) and HCO₃⁻ 16 mmol/L, with Na⁺ 145 and Cl⁻ 94 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 rhythm with PVCs
2first-degree AV block
3atrial fibrillation
4normal sinus rhythm
40.ECG rhythm strip interpretationHard
Interpret this lead II strip. Which interpretation can you defend from this single 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
12:1 AV block (type undetermined)
2third-degree (complete) AV block
3second-degree AV block type I (Wenckebach)
4sinus bradycardia
3Solutions
1.Nursing fundamentals
Answer: C · In the morning, from a deep cough, before antibiotics start
Why this is the answer
An early-morning sample from deep in the chest gives the best yield. Saliva is not sputum, and antibiotics can stop organisms growing in the lab.
Answer
C · In the morning, from a deep cough, before antibiotics start
2.Nursing fundamentals
Answer: A · The patient wears a surgical mask during transport
Why this is the answer
When an airborne-precaution patient must leave the room, they wear a surgical mask to contain respiratory secretions. Staff in close contact still wear respirators as per policy, and the receiving department is informed.
Answer
A · The patient wears a surgical mask during transport
3.Infection control & patient safety
Answer: B · A sporicidal agent, such as a chlorine-based solution
Why this is the answer
C. difficile spores resist alcohol and many standard disinfectants, so a sporicidal agent such as a chlorine-based product is used for the environment and equipment.
Answer
B · A sporicidal agent, such as a chlorine-based solution
4.Infection control & patient safety
Answer: A · Report it and fix the system, for example by separating the vials
Why this is the answer
A just culture recognizes that human errors are often caused by system design. Separating look-alike drugs, using labels and Tall Man lettering prevents repeats. Blaming the person alone leaves the hazard in place.
Answer
A · Report it and fix the system, for example by separating the vials
5.Prioritization & delegation
Answer: A · Diphenhydramine
Why this is the answer
Diphenhydramine is strongly anticholinergic and can cause confusion, urinary retention and falls in older adults. It is on lists of drugs to avoid in this group.
Answer
A · Diphenhydramine
6.Prioritization & delegation
Answer: C · IV calcium gluconate
Why this is the answer
IV calcium stabilizes the cardiac cell membranes within minutes and is given first when hyperkalemia changes the ECG. Insulin with glucose, binders and diuretics then lower the potassium.
Answer
C · IV calcium gluconate
7.Clinical nursing
Answer: D · 0.5 × 109/L
Why this is the answer
Neutropenic sepsis is defined by a neutrophil count of 0.5 × 109/L or lower with fever or other signs of sepsis. It needs empirical antibiotics within one hour.
Answer
D · 0.5 × 109/L
8.Clinical nursing
Answer: A · Adequate pain relief, IV fluids and close fluid balance monitoring
Why this is the answer
Acute pancreatitis can cause large fluid losses and organ failure. Care focuses on fluid resuscitation, analgesia, monitoring urine output, glucose and early nutrition when possible.
Answer
A · Adequate pain relief, IV fluids and close fluid balance monitoring
9.Lab values & electrolytes
Answer: A · Average glucose over the past months has been above the target
Why this is the answer
An HbA1c of 7.8% shows that average glucose has been above the individual target over about 2–3 months. The nurse explores diet, activity, medication use and barriers, and the treatment plan may be adjusted.Checked against:Hemoglobin A1C (HbA1c) Test · MedlinePlus (NIH) (2025)
Answer
A · Average glucose over the past months has been above the target
10.Lab values & electrolytes
Answer: B · High calcium increases the risk of digoxin toxicity
Why this is the answer
Hypercalcemia, like hypokalemia and hypomagnesemia, makes the heart more sensitive to digoxin and raises the risk of toxic arrhythmias. Nausea and bradycardia suggest toxicity, so the nurse holds the dose and reports the findings.
Answer
B · High calcium increases the risk of digoxin toxicity
11.Pharmacology
Answer: D · A common infusion reaction to amphotericin B
Why this is the answer
Amphotericin B often causes fever, rigors and nausea during infusion. Premedication and a slower rate can reduce them, and kidney function and electrolytes are monitored.
Answer
D · A common infusion reaction to amphotericin B
12.Pharmacology
Answer: D · At high doses it also stimulates beta receptors in skeletal muscle and the heart
Why this is the answer
Tremor comes from beta-2 stimulation of skeletal muscle. Tachycardia comes from some beta-1 (and cardiac beta-2) stimulation and a reflex response to vasodilation. High doses also shift potassium into cells and can cause hypokalaemia.
Answer
D · At high doses it also stimulates beta receptors in skeletal muscle and the heart
13.Med-surg: cardiovascular & respiratory
Answer: C · The reading will be falsely high
Why this is the answer
A cuff that is too small needs a higher pressure to compress the brachial artery, giving a falsely high reading. A cuff that is too large can give a falsely low reading. The bladder should encircle most of the arm, so cuff size is chosen by arm circumference.
Answer
C · The reading will be falsely high
14.Med-surg: cardiovascular & respiratory
Answer: C · A vagal response to straining
Why this is the answer
Straining (the Valsalva manoeuvre) can cause a vagal bradycardia and a fall in cardiac output, leading to syncope. After an MI, stool softeners, adequate fluids and avoiding straining are advised. The event is still reported and the patient assessed for arrhythmia or ischaemia.
Answer
C · A vagal response to straining
15.Med-surg: neuro, endocrine & renal
Answer: C · Magnesium-containing antacids
Why this is the answer
Magnesium and aluminium are excreted by the kidneys and can accumulate in kidney failure. Patients with CKD should check with a pharmacist before using over-the-counter remedies, including laxatives and NSAIDs.
Answer
C · Magnesium-containing antacids
16.Med-surg: neuro, endocrine & renal
Answer: C · Secondary hyperparathyroidism from CKD
Why this is the answer
In CKD, phosphate retention and low active vitamin D lower calcium, so the parathyroid glands release more PTH. This secondary hyperparathyroidism weakens bone. Treatment includes phosphate control, vitamin D and sometimes calcimimetics.
Answer
C · Secondary hyperparathyroidism from CKD
17.Med-surg: GI, perioperative & oncology
Answer: D · IV fluids followed by an IV bisphosphonate
Why this is the answer
Hypercalcaemia causes polyuria and dehydration, so IV saline is given first, then a bisphosphonate such as zoledronic acid to reduce bone resorption. Calcium, kidney function and symptoms are monitored.
Answer
D · IV fluids followed by an IV bisphosphonate
18.Med-surg: GI, perioperative & oncology
Answer: D · Use an observational pain tool, give analgesia and reassess
Why this is the answer
In dementia, pain often appears as agitation or guarding. An observational tool supports assessment; analgesia is given and effect reassessed. The hip is also assessed for injury such as a fracture.
Answer
D · Use an observational pain tool, give analgesia and reassess
19.Maternity & obstetric nursing
Answer: D · Blood flow to the placenta is restored between contractions
Why this is the answer
During contractions, blood flow to the intervillous space falls. Relaxation between contractions restores oxygen delivery to the fetus. Short rest periods, as in tachysystole, can cause fetal hypoxia.
Answer
D · Blood flow to the placenta is restored between contractions
20.Maternity & obstetric nursing
Answer: A · Twin-to-twin transfusion syndrome
Why this is the answer
In monochorionic twins, unbalanced vascular connections can shunt blood from one twin to the other. The recipient becomes overloaded with polyhydramnios, while the donor has low fluid and growth restriction.
Answer
A · Twin-to-twin transfusion syndrome
21.Pediatric nursing
Answer: C · Appetite falls as growth slows; offer small, healthy portions without pressure
Why this is the answer
Growth slows after the first year, so toddlers often eat less (sometimes called physiological anorexia). Offering small portions, regular meals and snacks and avoiding battles over food is advised; too much milk can reduce appetite and cause iron deficiency.
Answer
C · Appetite falls as growth slows; offer small, healthy portions without pressure
22.Pediatric nursing
Answer: B · A life-threatening deterioration with exhaustion and very poor air movement
Why this is the answer
A "silent chest" and drowsiness mean that too little air is moving and the child is tiring. This is an emergency: call for help, give oxygen and emergency treatment as ordered.
Answer
B · A life-threatening deterioration with exhaustion and very poor air movement
23.Mental health nursing
Answer: D · Fasting for several hours, because a brief general anaesthetic is given
Why this is the answer
ECT is given under brief general anaesthesia with a muscle relaxant, so pre-procedure fasting is needed. Vital signs, consent and removal of dentures, jewellery and nail varnish are checked as per policy.
Answer
D · Fasting for several hours, because a brief general anaesthetic is given
24.Mental health nursing
Answer: B · "Let's slow down and talk about one thing at a time. What worries you most right now?"
Why this is the answer
Focusing directs the conversation to one main concern, which reduces overwhelm and makes the problem easier to work on. A calm, slow pace from the nurse also helps lower anxiety.
Answer
B · "Let's slow down and talk about one thing at a time. What worries you most right now?"
25.Nursing math & unit conversions
Answer: T = 100.8 °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
38.2·9/5 = 68.76
Add 32
T = 68.76 + 32 = 100.8 °F
Answer
T = 100.8 °F
26.Nursing math & unit conversions
Answer: V = 227.5 mL
Household measures and weight: nursing exams use rounded equivalents: 1 teaspoon (tsp) = 5 mL, 1 tablespoon (tbsp) = 15 mL = 3 tsp, 1 fluid ounce (fl oz) = 30 mL = 2 tbsp, and 1 cup = 8 fl oz = 240 mL. For weight, 1 kg = 2.2 lb and 1 lb = 16 oz; for length, 1 inch = 2.54 cm. Set the conversion up so that the unit you do not want cancels out.
Each item in mL
6 fl oz = 6·30 = 180 mL
½ tsp = 0.5·5 = 2.5 mL
3 tbsp = 3·15 = 45 mL
Add
V = 180 + 2.5 + 45 = 227.5 mL
Answer
V = 227.5 mL
27.Dosage calculations
Answer: V = 3 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Concentration after mixing
2000 mg/8 mL = 250 mg/mL
Volume
V = 750/250 = 3 mL
Answer
V = 3 mL
28.Dosage calculations
Answer: V = 0.3 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 1500/5000 = 0.3 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.3 mL
29.IV infusion rates
Answer: V = 90 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
30·60/60 = 30 mL/h
Volume
V = 30·3 = 90 mL
Answer
V = 90 mL
30.IV infusion rates
Answer: R = 15 mL/h
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
1000 mg/500 mL = 2 mg/mL
Dose per hour
0.5·60 = 30 mg/h
Pump rate
R = 30/2 = 15 mL/h
Answer
R = 15 mL/h
31.Pediatric & critical-care dosing
Answer: R = 27.6 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
15·92 = 1 380 units/h
Concentration
25 000/500 = 50 units/mL
Pump rate
R = 1380/50 = 27.6 mL/h
Answer
R = 27.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 13.1 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
800 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
6·58 = 348 mcg/min
348·60 = 20880 mcg/h
Pump rate
R = 20880/1600 = 13.05 ≈ 13.1 mL/h
Answer
R = 13.1 mL/h
33.IV fluids & fluid balance
Answer: U = 1.37 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 + 300 = 625 mL
Per kilogram per hour
U = 625/(57·8) = 1.371 ≈ 1.37 mL/kg/h
Answer
U = 1.37 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 6.5 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
80·3 = 240 mL
500 − 240 = 260 mL left
Second part
260/75 = 3.467 h
Total time
t = 3 + 3.467 = 6.467 ≈ 6.5 h
Answer
t = 6.5 h
That is about 6 h 28 min, so the bag runs out at about 22:28.
35.Clinical assessment scores
Answer: MFS = 80
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: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: yes → 20
gait: impaired → 20
mental status: knows own limits → 0
Add
Morse total = 25 + 15 + 0 + 20 + 20 + 0 = 80
Answer
MFS = 80
36.Clinical assessment scores
Answer: obesity class I
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 118/1.86² = 34.11
Category
obesity class I
Answer
obesity class I
37.Arterial blood gas interpretation
Answer: fully compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.44: within 7.35–7.45
PaCO₂ 23 mmHg: low (35–45)
HCO₃⁻ 15 mmol/L: low (22–26)
Compensation
fully compensated
Answer
fully compensated
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 = 145 − (94 + 16) = 35
Delta ratio
(35 − 12)/(24 − 16) = 2.875
added metabolic alkalosis
Answer
added metabolic alkalosis
39.ECG rhythm strip interpretation
Answer: sinus rhythm with PVCs
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.
Five steps
1. Rate: 7 QRS complexes in 6 s, × 10 = 70 per minute.
2. Rhythm: regular (0.88 s) except for the early beats and the pause after each of them.
3. P waves: upright before every narrow QRS; none before the early wide beats.
4. PR interval: 0.16 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s in the sinus beats; the early beats are wide (0.14 s) and bizarre, with the T wave pointing the other way.
Interpretation
sinus rhythm with PVCs
Answer
sinus rhythm with PVCs
40.ECG rhythm strip interpretation
Answer: 2:1 AV block (type undetermined)
2:1 AV block: with two P waves for every QRS, no two conducted P waves follow each other, so you cannot see whether the PR would lengthen (type I) or stay constant (type II) before a non-conducted P wave. From one strip it is called a 2:1 AV block; a longer strip or a change in the conduction ratio decides the type. A narrow QRS makes type I more likely and a wide QRS type II, but neither proves it.
Five steps
1. Rate: R–R = 40 small boxes, 1500 ÷ 40 ≈ 38 per minute.
2. Rhythm: regular, every R–R is 1.60 s.
3. P waves: upright and regular (P–P 0.80 s, 75 per minute), two for every QRS.
4. PR interval: constant at 0.20 s in the conducted beats.
5. QRS: 0.08 s, narrow (below 0.12 s).
Why the type stays open
Every second P wave is not conducted, so no two conducted beats follow each other and a lengthening PR could never show.
2:1 AV block (type undetermined)
Answer
2:1 AV block (type undetermined)
A narrow QRS makes type I more likely and a wide QRS type II, but only a longer strip or a change in the conduction ratio decides.
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