Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
Why should enteric-coated tablets not be crushed?
ACrushing removes the coating that protects the stomach or drug
BCrushing makes the drug inactive in water
CCrushing makes the tablet taste so bitter that patients refuse it
DCrushing makes the dose roughly twice as strong as the whole tablet
2.Nursing fundamentalsHard
A young patient with type 1 diabetes has deep, rapid breathing, a fruity smell on the breath, vomiting and signs of dehydration. What should you suspect?
AHypoglycaemia
BHyperventilation from anxiety
CA simple viral stomach infection
DDiabetic ketoacidosis
3.Infection control & patient safetyMedium
Which practice is safe when transferring a patient from a bed to a stretcher?
ALeave the stretcher wheels unlocked so it can move with the patient
BLower the stretcher side rails during transport
CHave the patient slide across without help or a slide sheet
DLock the wheels of both the bed and the stretcher before moving the patient
4.Infection control & patient safetyHard
A patient with depression has suddenly become calm and is giving away personal possessions. What does this suggest?
AThat the depression has resolved and observation can be reduced
BThat the patient wants to make new friends on the unit
CThat the patient is now ready for discharge today
DA possibly increased suicide risk that needs immediate assessment
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?
AAcetaminophen (paracetamol)
BMelatonin
CA warm milky drink
DDiphenhydramine
6.Prioritization & delegationHard
A patient after major surgery has a urine output of 15 mL/h for two hours, a heart rate of 115/min and cool hands. What should the nurse do first?
AFlush the catheter and recheck the output tomorrow morning
BAssess for signs of shock, such as bleeding, and escalate
CWait another two hours to see whether the output improves
DEncourage the patient to drink more water and recheck later
7.Clinical nursingMedium
Which group of symptoms suggests hypercalcaemia?
AWeight gain, feeling cold and a slow pulse
BSweating, tremor and sudden hunger
CThirst, constipation, confusion and abdominal pain
DTingling lips, muscle cramps and spasms of the hands and feet
8.Clinical nursingHard
Why are early surgery and early mobilisation recommended for older patients with a hip fracture?
AThey reduce complications such as pneumonia, pressure ulcers and delirium
BThey mainly reduce the cost of the operation
CThey allow the bone to heal fully without any need for pain relief
DThey make physiotherapy and rehabilitation unnecessary after discharge
9.Lab values & electrolytesMedium
When do the blood counts usually reach their lowest point (nadir) after many standard chemotherapy regimens?
AWithin 1–2 hours of treatment
BOn the same day as treatment
CAbout 7–14 days after treatment
DAbout 6 months after treatment
10.Lab values & electrolytesHard
Which patient should the nurse assess first?
AHypertension with a potassium of 3.6 mEq/L on a thiazide
BChest pain with troponin rising from the first to the second sample
CStable angina with a total cholesterol of 245 mg/dL (6.3 mmol/L)
DHeart failure with a BNP lower than the result on admission
11.PharmacologyMedium
Methylergometrine (methylergonovine) is prescribed for postpartum bleeding. Which finding would make the nurse withhold it and check with the prescriber?
AHeart rate of 88 per minute
BTemperature of 37.2 °C (99 °F)
CHaemoglobin slightly below normal
DBlood pressure of 160/105 mmHg
12.PharmacologyHard
A teenager took a large overdose of diphenhydramine. He is agitated, hot, flushed and confused, with dry skin, dilated pupils and a full bladder. What is this pattern?
AOpioid toxidrome
BSerotonin syndrome
CCholinergic toxidrome
DAnticholinergic toxidrome
13.Med-surg: cardiovascular & respiratoryMedium
Where is the V1 electrode placed for a 12-lead ECG?
AThe fourth intercostal space just right of the sternum
BOver the left nipple
CThe fifth intercostal space in the mid-axillary line
DJust below the left collarbone
14.Med-surg: cardiovascular & respiratoryHard
An older ex-smoker has a dry cough and worsening breathlessness over a year, finger clubbing and fine "Velcro-like" crackles at both bases at the end of inspiration. Which condition is most likely?
ACommunity-acquired pneumonia
BIdiopathic pulmonary fibrosis
CSpontaneous pneumothorax
DAn acute asthma attack
15.Med-surg: neuro, endocrine & renalMedium
Why should antiepileptic drugs not be stopped suddenly?
ASudden withdrawal can trigger seizures, including status epilepticus
BThe drugs build up in the body and become toxic after stopping
CStopping them suddenly causes a dangerous rise in blood pressure
DStopping them suddenly causes permanent damage to the liver and kidneys
16.Med-surg: neuro, endocrine & renalHard
An 84-year-old man became more confused a week after starting oxybutynin. Infection has been ruled out. What should the nurse suspect?
ANormal ageing that needs no review
BA symptom of a high potassium from the drug
CAnticholinergic side effects of the drug
DA sign that the drug dose is too low
17.Med-surg: GI, perioperative & oncologyMedium
Which lifestyle change most improves the course of Crohn's disease?
AEating more red meat
BStopping smoking
CDrinking more coffee
DAvoiding all exercise
18.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient with chronic pancreatitis. Which statement shows a need for further teaching?
A"I'll report increased thirst or passing urine more often."
B"I'll take my enzyme capsules at bedtime."
C"I should not drink any alcohol."
D"Oily, floating stools may mean my dose needs changing."
19.Maternity & obstetric nursingMedium
The first day of a woman's last menstrual period was 10 March. Using Naegele's rule, what is her estimated date of birth?
A3 December
B17 June
C10 January
D17 December
20.Maternity & obstetric nursingHard
Just after the membranes rupture, there is painless vaginal bleeding and the fetal heart rate drops sharply. The mother's vital signs are normal. Which condition is most likely?
ABloody show
BRuptured vasa praevia
CUterine rupture
DPlacental abruption
21.Pediatric nursingMedium
How does hydroxyurea (hydroxycarbamide) help children with sickle cell disease?
AIt increases fetal haemoglobin, which reduces sickling
BIt replaces the missing clotting factors
CIt kills bacteria in the blood and prevents infections
DIt removes extra iron after blood transfusions
22.Pediatric nursingHard
A conscious 3-year-old is choking on food and cannot cough, cry or speak. What should the nurse do?
ADo a blind finger sweep of the mouth to hook out the piece of food
BWait to see if the child coughs it up
CGive the child water to swallow
DGive back blows and then abdominal thrusts, and call for help
23.Mental health nursingMedium
A patient from a culture in which communication with ancestors is common says she sometimes hears her late grandmother giving advice. What is the most appropriate nursing approach?
AAvoid asking about it, because culture is not relevant to mental health
BExplore the experience in her cultural context before calling it a symptom
CRecord it immediately as a command hallucination
DTell her that her beliefs are not real
24.Mental health nursingHard
A caller says she is a patient's sister and asks how he is doing. The patient has not given consent to share information. What should the nurse do?
ANeither confirm nor deny that he is there, and offer to pass on a message
BGive a full update, because she is a close family member
CAsk her to prove she is his sister and then share the details
DTell her that he is on the ward but refuse to say anything else about his care or condition
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 100.5 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
100.5 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A haemoglobin result is 14.7 g/dL. Express it in g/L Hb.
14.7 g/dL1 L = 10 dL
Hb = g/L
27.Dosage calculationsMedium
A child weighing 14 kg is prescribed 7.5 mg/kg of a drug. The stock solution contains 25 mg/mL. Draw up the dose: what volume V do you give?
14 kg7.5 mg/kg25 mg/mL
V = mL
28.Dosage calculationsHard
An infusion contains 40000 units of a drug in 500 mL. The prescription is 1000 units per hour. At what rate R do you set the pump, in mL/h?
40000 units/500 mL1000 units/h
R = mL/h
29.IV infusion ratesMedium
A drip runs at 25 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 8 hours?
25 gtt/min15 gtt/mL8 h
V = mL
30.IV infusion ratesHard
A drip runs at 32 gtt/min through a set of 20 gtt/mL. There are 600 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
32 gtt/min20 gtt/mL600 mL
t = h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 60 units/kg for a patient who weighs 53 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
60 units/kg53 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 65 kg has an order for nitroglycerin at 40 mcg/min. The bag contains 50 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
50 mg/250 mL40 mcg/min65 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 91 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
91 kg8 hurine: 350 mLurine: 375 mLurine: 350 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 150 mL/h. At 10:30, 300 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL300 mL infused150 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient after a head injury opens the eyes when spoken to, says inappropriate, random words and shows as the best motor response: abnormal flexion of the arms (decorticate posture). 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). The team aims for a mean arterial pressure of at least 65 mmHg. A patient’s systolic pressure is 85 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 85 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 18 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 18 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 24% oxygen shows PaO₂ 76 mmHg (10.1 kPa) and PaCO₂ 50 mmHg (6.7 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
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
1supraventricular tachycardia (SVT)
2sinus tachycardia
3atrial fibrillation
4atrial flutter, 2:1 conduction
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. 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
1second-degree AV block type II
2third-degree (complete) AV block
3second-degree AV block type I (Wenckebach)
4first-degree AV block
3Solutions
1.Nursing fundamentals
Answer: A · Crushing removes the coating that protects the stomach or drug
Why this is the answer
Enteric coatings stop the tablet dissolving until it reaches the small intestine, protecting the stomach lining or the drug from stomach acid. Crushing destroys this protection.
Answer
A · Crushing removes the coating that protects the stomach or drug
2.Nursing fundamentals
Answer: D · Diabetic ketoacidosis
Why this is the answer
Without enough insulin, fat breakdown produces ketones, causing metabolic acidosis. Deep breathing (Kussmaul), ketotic breath, high glucose and dehydration are typical. It is an emergency.
Answer
D · Diabetic ketoacidosis
3.Infection control & patient safety
Answer: D · Lock the wheels of both the bed and the stretcher before moving the patient
Why this is the answer
Both surfaces are locked and at the same height before the transfer, a slide sheet is used and enough staff help. Side rails are raised on the stretcher during transport.
Answer
D · Lock the wheels of both the bed and the stretcher before moving the patient
4.Infection control & patient safety
Answer: D · A possibly increased suicide risk that needs immediate assessment
Why this is the answer
A sudden improvement in mood with giving away belongings can mean the person has made a plan. The nurse assesses suicide risk directly, increases observation and informs the team.
Answer
D · A possibly increased suicide risk that needs immediate assessment
5.Prioritization & delegation
Answer: D · 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
D · Diphenhydramine
6.Prioritization & delegation
Answer: B · Assess for signs of shock, such as bleeding, and escalate
Why this is the answer
These signs together suggest hypovolemia or shock. The nurse assesses the whole patient, looks for bleeding and escalates. A catheter problem should be ruled out, but it should not delay recognition of shock.
Answer
B · Assess for signs of shock, such as bleeding, and escalate
7.Clinical nursing
Answer: C · 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
C · Thirst, constipation, confusion and abdominal pain
8.Clinical nursing
Answer: A · They reduce complications such as pneumonia, pressure ulcers and delirium
Why this is the answer
Delayed surgery and immobility increase the risk of chest infection, VTE, pressure ulcers, delirium and loss of independence. Guidelines recommend surgery within about 24–48 hours of admission (UK guidance: the day of or day after) and mobilisation soon after.
Answer
A · They reduce complications such as pneumonia, pressure ulcers and delirium
9.Lab values & electrolytes
Answer: C · About 7–14 days after treatment
Why this is the answer
Chemotherapy damages dividing marrow cells, but mature neutrophils and platelets already in the blood survive for a while, so counts usually fall to a nadir about 7–14 days later, depending on the drug. Infection and bleeding risks are highest then.
Answer
C · About 7–14 days after treatment
10.Lab values & electrolytes
Answer: B · Chest pain with troponin rising from the first to the second sample
Why this is the answer
A rising troponin with chest pain indicates acute myocardial injury, possibly infarction, which needs urgent assessment and treatment. High cholesterol is a long-term risk, a falling BNP shows improvement, and a potassium of 3.6 mEq/L is normal.Checked against:Troponin Test · MedlinePlus (NIH) (2023)
Answer
B · Chest pain with troponin rising from the first to the second sample
11.Pharmacology
Answer: D · Blood pressure of 160/105 mmHg
Why this is the answer
Ergot alkaloids cause vasoconstriction and can raise blood pressure sharply. They are contraindicated in hypertension and pre-eclampsia.
Answer
D · Blood pressure of 160/105 mmHg
12.Pharmacology
Answer: D · Anticholinergic toxidrome
Why this is the answer
Anticholinergic toxicity causes hyperthermia, dry flushed skin, mydriasis, urinary retention, tachycardia and delirium. Dry skin helps distinguish it from serotonin syndrome and sympathomimetic poisoning, which cause sweating.
Answer
D · Anticholinergic toxidrome
13.Med-surg: cardiovascular & respiratory
Answer: A · The fourth intercostal space just right of the sternum
Why this is the answer
V1 is placed in the fourth intercostal space at the right sternal edge, and V2 at the left sternal edge. V4 is in the fifth intercostal space in the mid-clavicular line, and V6 in the mid-axillary line at the same level. Wrong placement can mimic or hide changes.
Answer
A · The fourth intercostal space just right of the sternum
14.Med-surg: cardiovascular & respiratory
Answer: B · Idiopathic pulmonary fibrosis
Why this is the answer
Idiopathic pulmonary fibrosis causes progressive breathlessness, a dry cough, clubbing and fine end-inspiratory crackles. Spirometry shows a restrictive pattern and CT shows fibrosis. Treatment includes antifibrotic drugs, pulmonary rehabilitation, oxygen and palliative care.
Answer
B · Idiopathic pulmonary fibrosis
15.Med-surg: neuro, endocrine & renal
Answer: A · Sudden withdrawal can trigger seizures, including status epilepticus
Why this is the answer
Stopping antiepileptics abruptly can cause rebound seizures, which may be prolonged. Changes are made gradually under medical supervision, and missed doses should be avoided.
Answer
A · Sudden withdrawal can trigger seizures, including status epilepticus
16.Med-surg: neuro, endocrine & renal
Answer: C · Anticholinergic side effects of the drug
Why this is the answer
Anticholinergic drugs such as oxybutynin can cause confusion and worsen cognition in older people. The prescriber should review the medicine and the patient's overall anticholinergic burden.
Answer
C · Anticholinergic side effects of the drug
17.Med-surg: GI, perioperative & oncology
Answer: B · Stopping smoking
Why this is the answer
Smoking worsens Crohn's disease, increasing flares, complications and the need for surgery. Stopping smoking is one of the most effective changes a patient can make.
Answer
B · Stopping smoking
18.Med-surg: GI, perioperative & oncology
Answer: B · "I'll take my enzyme capsules at bedtime."
Why this is the answer
Pancreatic enzymes must be taken with meals and snacks to digest them. Alcohol must be avoided, steatorrhoea suggests under-replacement, and thirst or polyuria can signal diabetes from loss of islet cells.
Answer
B · "I'll take my enzyme capsules at bedtime."
19.Maternity & obstetric nursing
Answer: D · 17 December
Why this is the answer
10 March + 7 days = 17 March; minus 3 months = 17 December. Subtracting the 7 days instead gives 3 December, and adding the 3 months gives 17 June.
Answer
D · 17 December
20.Maternity & obstetric nursing
Answer: B · Ruptured vasa praevia
Why this is the answer
Rupture of the membranes can tear unprotected fetal vessels in vasa praevia. Fetal blood loss causes rapid bradycardia while the mother stays stable. An emergency caesarean is needed.
Answer
B · Ruptured vasa praevia
21.Pediatric nursing
Answer: A · It increases fetal haemoglobin, which reduces sickling
Why this is the answer
Hydroxyurea raises the level of fetal haemoglobin (HbF), which does not sickle, reducing pain crises and acute chest syndrome. Regular blood counts are needed because it can lower white cells and platelets.
Answer
A · It increases fetal haemoglobin, which reduces sickling
22.Pediatric nursing
Answer: D · Give back blows and then abdominal thrusts, and call for help
Why this is the answer
For a conscious child over 1 year with an ineffective cough, give up to 5 back blows, then up to 5 abdominal thrusts, and repeat. A blind finger sweep can push the object further in. If the child becomes unresponsive, start CPR.
Answer
D · Give back blows and then abdominal thrusts, and call for help
23.Mental health nursing
Answer: B · Explore the experience in her cultural context before calling it a symptom
Why this is the answer
A belief or experience that is accepted in the person's culture is not classed as a delusion or hallucination in itself. The nurse explores its meaning, how it is shared by others and whether it causes distress.
Answer
B · Explore the experience in her cultural context before calling it a symptom
24.Mental health nursing
Answer: A · Neither confirm nor deny that he is there, and offer to pass on a message
Why this is the answer
Without the patient's consent, the nurse should not disclose that a person is receiving mental health care. Offering to pass on a message respects confidentiality while allowing the patient to decide.
Answer
A · Neither confirm nor deny that he is there, and offer to pass on a message
25.Nursing math & unit conversions
Answer: T = 38.1 °C
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.
Subtract 32
100.5 − 32 = 68.5
Multiply by 5/9
T = 68.5·5/9 = 38.06 ≈ 38.1 °C
Answer
T = 38.1 °C
26.Nursing math & unit conversions
Answer: Hb = 147 g/L
Dimensional analysis: write the given quantity, then multiply by conversion factors written as fractions (for example 60 min/1 h or 1 mg/1000 mcg) so that each unwanted unit appears once on top and once underneath and cancels. When only the wanted unit is left, calculate. Use the equivalents the question gives and round only the final answer.
Convert
Hb = 14.7 g/dL × 10 dL/L = 147 g/L
Answer
Hb = 147 g/L
27.Dosage calculations
Answer: V = 4.2 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 = 7.5·14 = 105 mg
Volume
V = 105/25 = 4.2 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4.2 mL
28.Dosage calculations
Answer: R = 12.5 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
40000/500 = 80 units/mL
Pump rate
R = 1000/80 = 12.5 mL/h
Answer
R = 12.5 mL/h
29.IV infusion rates
Answer: V = 800 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Rate in mL/h
25·60/15 = 100 mL/h
Volume
V = 100·8 = 800 mL
Answer
V = 800 mL
30.IV infusion rates
Answer: t = 6.3 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.
Rate in mL/h
32·60/20 = 96 mL/h
Time left
t = 600/96 = 6.25 ≈ 6.3 h
Answer
t = 6.3 h
31.Pediatric & critical-care dosing
Answer: V = 3.2 mL
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 needed
60·53 = 3 180 units
Volume
V = 3180/1000 = 3.18 ≈ 3.2 mL
Answer
V = 3.2 mL
32.Pediatric & critical-care dosing
Answer: R = 12 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
50 000/250 = 200 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
40·60 = 2400 mcg/h
Pump rate
R = 2400/200 = 12 mL/h
Answer
R = 12 mL/h
33.IV fluids & fluid balance
Answer: U = 1.48 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
350 + 375 + 350 = 1075 mL
Per kilogram per hour
U = 1075/(91·8) = 1.477 ≈ 1.48 mL/kg/h
Answer
U = 1.48 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 1.3 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.
Volume left
500 − 300 = 200 mL
Time
t = 200/150 = 1.333 ≈ 1.3 h
Answer
t = 1.3 h
That is about 1 h 20 min, so the bag runs out at about 11:50.
35.Clinical assessment scores
Answer: moderate
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: opens the eyes when spoken to → 3
V: says inappropriate, random words → 3
M: abnormal flexion of the arms (decorticate posture) → 3
Add
GCS = 3 + 3 + 3 = 9
Severity
GCS 9 → moderate
Answer
moderate
36.Clinical assessment scores
Answer: DBP = 55 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 − 85)/2 = 110/2 = 55 mmHg
Answer
DBP = 55 mmHg
37.Arterial blood gas interpretation
Answer: PaCO₂ = 35 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 = 1.5·18 + 8 = 35 mmHg
range: 33–37 mmHg
Answer
PaCO₂ = 35 mmHg
38.Arterial blood gas interpretation
Answer: A–a gradient = 32.62 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
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 = 9 small boxes, 1500 ÷ 9 ≈ 167 per minute.
2. Rhythm: regular, every R–R is 0.36 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: 0.08 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: second-degree AV block type I (Wenckebach)
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.
Five steps
1. Rate: 4 QRS complexes in 6 s, × 10 = 40 per minute.
2. Rhythm: regularly irregular, the QRS complexes come in groups separated by a pause (group beating).
3. P waves: upright and regular (P–P 0.92 s, 65 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: lengthens 0.16 → 0.30 s, then a P wave is not conducted.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
second-degree AV block type I (Wenckebach)
Answer
second-degree AV block type I (Wenckebach)
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