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 approach suits teaching an older adult with poor eyesight and mild memory problems?
AA detailed leaflet in small print for them to read later at home
BOne long session with all the information at once
CShort sessions, large-print materials and repeating key points
DTeaching only the family and not the patient
2.Nursing fundamentalsHard
Which patient should the nurse see first?
AA patient who is waiting for their discharge letter and medicines
BA postoperative patient with SpO₂ 89% on air and a respiratory rate of 28
CA patient who is asking for help to walk to the toilet now
DA patient with a pain score of 3/10 whose analgesia is due in an hour
3.Infection control & patient safetyMedium
Why should a child’s weight be recorded only in kilograms?
AScales that show kilograms are always more accurate than those that show pounds
BKilograms are easier for parents to remember
CChildren weigh less, so smaller units are needed
DMixing up pounds and kilograms can lead to large dosing errors
4.Infection control & patient safetyHard
A confused patient keeps pulling at a nasogastric tube. Which approach should be tried first?
AA sedative so that the patient sleeps quietly through the night
BWrist restraints straight away to protect the tube
CLess restrictive measures, such as reorientation and a sitter
DRemoving the tube without consulting the team
5.Prioritization & delegationMedium
A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?
A“I will keep my child home from school and away from others while unwell.”
B“I will give my child aspirin to bring the fever down.”
C“I will give my child plenty of fluids.”
D“I will call if my child has trouble breathing.”
6.Prioritization & delegationHard
After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?
ASeptic shock
BNeurogenic shock
CCardiac tamponade
DHypovolemic shock
7.Clinical nursingMedium
A patient with MRSA colonisation is admitted. Which precautions are appropriate?
AIsolation in a negative-pressure room for six months
BContact precautions with gloves, apron and good hand hygiene
CAirborne precautions with an FFP3 respirator mask for all staff
DNo precautions are needed for colonisation
8.Clinical nursingHard
A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?
APost-renal acute kidney injury from obstruction, treated with a catheter
BChronic kidney disease, treated with long-term dialysis three times a week
CPre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
DIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids
9.Lab values & electrolytesMedium
A patient with schizophrenia is starting clozapine. Which laboratory value must be monitored regularly?
AAbsolute neutrophil count
BSerum amylase
CInternational normalized ratio
DSerum lithium level
10.Lab values & electrolytesHard
After chemotherapy for a fast-growing lymphoma, which pattern of results suggests tumor lysis syndrome?
AHigh potassium, high phosphate, high uric acid and low calcium
BNormal electrolytes with a high hemoglobin
CHigh sodium and low glucose only
DLow potassium, low phosphate, low uric acid and a raised calcium
11.PharmacologyMedium
Which side effect is typical of the calcium channel blocker amlodipine?
AAnkle swelling
BHyperkalaemia
CBronchospasm
DDry cough
12.PharmacologyHard
Why is strict aseptic technique and a limited hang time needed for propofol infusions?
APropofol becomes more potent the longer it hangs
BLight exposure changes propofol into an opioid
CIts lipid emulsion lets bacteria grow if it is contaminated
DPropofol breaks down into a toxic gas after a few hours
13.Med-surg: cardiovascular & respiratoryMedium
A patient has central chest pain and a STEMI on the ECG. What does this usually require?
AA troponin result before any treatment decision is made
BOral beta-blocker and discharge if pain settles
CEmergency reperfusion, preferably by primary PCI
DAdmission and a repeat ECG the next morning
14.Med-surg: cardiovascular & respiratoryHard
Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?
ASternal wound infection with an unstable sternum
BPericarditis from the operation
CNormal wound healing with some expected discharge
DCostochondritis caused by forceful coughing
15.Med-surg: neuro, endocrine & renalMedium
A patient with a right-hemisphere stroke ignores food on the left side of the plate. What is this called?
AExpressive aphasia
BCerebellar ataxia
CLeft-sided neglect
DDysphagia
16.Med-surg: neuro, endocrine & renalHard
A man with chronic urinary retention is catheterised. Over the next hours he passes very large volumes of urine. What is the main nursing concern?
AFluid and electrolyte loss from post-obstructive diuresis
BRupture of the bladder from the catheter
CA rise in blood glucose from the urine
DA urinary infection caused by the high flow of urine
17.Med-surg: GI, perioperative & oncologyMedium
Which bedside assessments are used to follow ascites?
ADaily weight and abdominal girth
BPupil size and reaction twice daily
CPeak flow and oxygen saturation
DCapillary glucose before each meal
18.Med-surg: GI, perioperative & oncologyHard
After a high-voltage electrical injury, a patient's urine is dark red-brown. What does this suggest and what is the usual aim?
AA urinary infection; send a sample and wait for the result
BMyoglobin from muscle damage; a higher urine output target
CBleeding from the bladder; stop all fluids
DNormal concentrated urine; restrict fluids
19.Maternity & obstetric nursingMedium
Which pattern defines uterine tachysystole?
AContractions lasting 60 seconds
BMore than 5 contractions in 10 minutes, averaged over 30 minutes
CContractions every 5 minutes in early labour, each lasting 60 seconds
DMore than 2 contractions in 10 minutes
20.Maternity & obstetric nursingHard
A woman who had a stillbirth asks the nurse why it happened. What is the most appropriate response?
ATell her she should not have exercised
BChange the subject to avoid upsetting her
CTell her it was probably something she ate
DAcknowledge her grief; tests may find a cause
21.Pediatric nursingMedium
What is a normal capillary refill time in a child?
A2 seconds or less
B8 to 10 seconds
C5 seconds or less
D15 to 20 seconds
22.Pediatric nursingHard
A child with sickle cell disease has been exposed to parvovirus B19 (fifth disease). Why is this a concern?
AIt makes the child immune to all future crises
BIt triggers a severe allergic reaction to the virus
CIt can stop red cell production for days and cause severe anaemia
DIt causes the sickle gene to become active in the child
23.Mental health nursingMedium
In family systems theory, what is meant by the "identified patient"?
AThe member whose symptoms are seen as the family's problem
BThe family member who has the most serious physical illness
CThe patient whose identity has been checked against a wristband before treatment
DThe family member who pays for the treatment
24.Mental health nursingHard
During a ward community meeting, several patients complain that the ward is too noisy at night. What reflects a therapeutic milieu?
ATell the patients that the rules cannot be changed
BEnd the meeting so the complaint is not discussed further
CAsk the patients to write their complaints down and then do nothing
DDiscuss the problem openly and involve patients in finding a solution
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 36.5 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
36.5 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 1½ tbsp of liquid supplement, 1 tsp of cough syrup, 8 fl oz of juice. Using the equivalents given, find the total oral intake V in mL.
1 tbsp = 15 mL1 tsp = 5 mL1 fl oz = 30 mL
V = mL
27.Dosage calculationsMedium
A child weighing 17 kg is prescribed 20 mg/kg of a drug. The stock solution contains 50 mg/mL. Draw up the dose: what volume V do you give?
17 kg20 mg/kg50 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 2.16 mg. The ampoule contains 4000 micrograms per mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
2.16 mg4000 mcg/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 50 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 12 hours?
50 gtt/min15 gtt/mL12 h
V = mL
30.IV infusion ratesHard
A bag contains 1 g of a drug in 500 mL. The order is 4 mg per minute. At what rate R do you set the pump, in mL/h?
1 g/500 mL4 mg/min
R = mL/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 100 units of regular insulin in 100 mL runs at 8 mL/h. How many units per hour D does the patient receive?
100 units/100 mL8 mL/h
D = units/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 2 mcg/kg/min for a patient who weighs 86 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL2 mcg/kg/min86 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 fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 125 mL/h. At 15:30, 50 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL50 mL infused125 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 94/min and a blood pressure of 143/93 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 94/minBP 143/93 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 79 kg and is 161 cm tall. Calculate the BMI and click the WHO weight category.
79 kg161 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 58 mmHg (7.7 kPa). Use the rule that in chronic respiratory acidosis HCO₃⁻ rises by 3.5 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Fridericia’s formula QTc = QT/∛RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
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
1second-degree AV block type II
22:1 AV block (type undetermined)
3third-degree (complete) AV block
4first-degree AV block
3Solutions
1.Nursing fundamentals
Answer: C · Short sessions, large-print materials and repeating key points
Why this is the answer
Older learners benefit from short, focused sessions, clear large print, good lighting, repetition and teach-back. Involving family can help but should not replace teaching the patient.
Answer
C · Short sessions, large-print materials and repeating key points
2.Nursing fundamentals
Answer: B · A postoperative patient with SpO₂ 89% on air and a respiratory rate of 28
Why this is the answer
Low saturation with a high respiratory rate shows a breathing problem that could worsen quickly. The other needs are real but not urgent.
Answer
B · A postoperative patient with SpO₂ 89% on air and a respiratory rate of 28
3.Infection control & patient safety
Answer: D · Mixing up pounds and kilograms can lead to large dosing errors
Why this is the answer
Pediatric doses are often calculated per kilogram. A weight recorded in pounds but read as kilograms gives a dose more than twice as high, so weight is recorded and used only in kilograms.
Answer
D · Mixing up pounds and kilograms can lead to large dosing errors
4.Infection control & patient safety
Answer: C · Less restrictive measures, such as reorientation and a sitter
Why this is the answer
Less restrictive measures are tried first: reorientation, checking for causes such as pain, securing the tube out of sight and having someone stay with the patient. Restraints or sedatives are used only if these fail and the patient is at risk, with an order.
Answer
C · Less restrictive measures, such as reorientation and a sitter
5.Prioritization & delegation
Answer: B · “I will give my child aspirin to bring the fever down.”
Why this is the answer
Aspirin in children with viral illnesses such as influenza or chickenpox is linked to Reye syndrome. Fluids, rest at home and reporting breathing trouble are correct.
Answer
B · “I will give my child aspirin to bring the fever down.”
6.Prioritization & delegation
Answer: B · Neurogenic shock
Why this is the answer
Neurogenic shock follows loss of sympathetic tone, causing vasodilation, hypotension and bradycardia with warm skin. Hypovolemic shock usually causes a fast pulse and cool, clammy skin.
Answer
B · Neurogenic shock
7.Clinical nursing
Answer: B · Contact precautions with gloves, apron and good hand hygiene
Why this is the answer
MRSA is spread mainly by direct and indirect contact, so contact precautions, isolation where possible and strict hand hygiene limit transmission.
Answer
B · Contact precautions with gloves, apron and good hand hygiene
8.Clinical nursing
Answer: C · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
Why this is the answer
Fluid loss reduces kidney perfusion, causing pre-renal AKI. Prompt fluid replacement can restore function before the kidney tissue itself is damaged.
Answer
C · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
9.Lab values & electrolytes
Answer: A · Absolute neutrophil count
Why this is the answer
Clozapine can cause severe neutropenia (agranulocytosis), so the ANC is checked before starting and regularly during treatment. A sore throat, fever or other sign of infection must be reported at once.
Answer
A · Absolute neutrophil count
10.Lab values & electrolytes
Answer: A · High potassium, high phosphate, high uric acid and low calcium
Why this is the answer
When many tumor cells break down, potassium, phosphate and nucleic acids (which become uric acid) flood the blood. Phosphate binds calcium, so calcium falls. The risks include arrhythmias and acute kidney injury.Checked against:Tumor Lysis Syndrome (StatPearls) · StatPearls (NCBI Bookshelf) (2024)
Answer
A · High potassium, high phosphate, high uric acid and low calcium
11.Pharmacology
Answer: A · Ankle swelling
Why this is the answer
Dihydropyridine calcium channel blockers dilate arterioles, raising capillary pressure in the legs and causing ankle oedema. Dry cough is typical of ACE inhibitors.
Answer
A · Ankle swelling
12.Pharmacology
Answer: C · Its lipid emulsion lets bacteria grow if it is contaminated
Why this is the answer
Propofol is formulated in a soybean oil emulsion, which is a good growth medium for bacteria. Contaminated propofol has caused sepsis, so it is handled aseptically and tubing and containers are changed at set intervals.
Answer
C · Its lipid emulsion lets bacteria grow if it is contaminated
13.Med-surg: cardiovascular & respiratory
Answer: C · Emergency reperfusion, preferably by primary PCI
Why this is the answer
A STEMI usually reflects total occlusion of a coronary artery. Emergency reperfusion, preferably primary PCI (or thrombolysis if PCI cannot be done in time), is needed as soon as possible; "time is muscle". The decision is made on the ECG and symptoms, not on the troponin result.
Answer
C · Emergency reperfusion, preferably by primary PCI
14.Med-surg: cardiovascular & respiratory
Answer: A · Sternal wound infection with an unstable sternum
Why this is the answer
Deep sternal wound infection and sternal dehiscence are serious complications, more common with diabetes, obesity and COPD. Signs include fever, wound discharge, redness and an unstable or clicking sternum. Urgent surgical review, wound swabs, blood cultures and antibiotics are needed.
Answer
A · Sternal wound infection with an unstable sternum
15.Med-surg: neuro, endocrine & renal
Answer: C · Left-sided neglect
Why this is the answer
Right-hemisphere strokes commonly cause neglect of the left side of space and the body. The nurse may need to prompt the patient to scan to the left, and the environment should be arranged safely. Aphasia is typical of left-hemisphere damage.
Answer
C · Left-sided neglect
16.Med-surg: neuro, endocrine & renal
Answer: A · Fluid and electrolyte loss from post-obstructive diuresis
Why this is the answer
After relief of chronic obstruction, the kidneys may pass large volumes of urine and salt. Hypovolaemia and electrolyte problems can follow. Strict fluid balance, blood pressure checks and electrolyte monitoring are needed.
Answer
A · Fluid and electrolyte loss from post-obstructive diuresis
17.Med-surg: GI, perioperative & oncology
Answer: A · Daily weight and abdominal girth
Why this is the answer
Daily weights and abdominal girth measured at the same marked level show whether ascites is increasing or decreasing. Fluid balance, renal function and electrolytes are also monitored, especially on diuretics.
Answer
A · Daily weight and abdominal girth
18.Med-surg: GI, perioperative & oncology
Answer: B · Myoglobin from muscle damage; a higher urine output target
Why this is the answer
Electrical injury can cause extensive muscle breakdown, releasing myoglobin that can damage the kidneys. A higher urine output target is set, with fluids titrated and creatine kinase and kidney function monitored.
Answer
B · Myoglobin from muscle damage; a higher urine output target
19.Maternity & obstetric nursing
Answer: B · More than 5 contractions in 10 minutes, averaged over 30 minutes
Why this is the answer
Tachysystole is more than five contractions in 10 minutes averaged over 30 minutes. With oxytocin running, it is managed by reducing or stopping the infusion, especially if the fetal heart rate is affected.
Answer
B · More than 5 contractions in 10 minutes, averaged over 30 minutes
20.Maternity & obstetric nursing
Answer: D · Acknowledge her grief; tests may find a cause
Why this is the answer
The nurse acknowledges her grief, avoids blame and explains that investigations such as a post-mortem and placental examination may help find a cause, although often none is found.
Answer
D · Acknowledge her grief; tests may find a cause
21.Pediatric nursing
Answer: A · 2 seconds or less
Why this is the answer
A capillary refill time of 2 seconds or less is normal. A longer time suggests poor perfusion, as in dehydration or shock, though a cold environment can also prolong it.
Answer
A · 2 seconds or less
22.Pediatric nursing
Answer: C · It can stop red cell production for days and cause severe anaemia
Why this is the answer
Parvovirus B19 temporarily stops red cell production. Healthy children barely notice this, but in sickle cell disease red cells survive only a short time, so an aplastic crisis with severe anaemia can develop and may need transfusion.
Answer
C · It can stop red cell production for days and cause severe anaemia
23.Mental health nursing
Answer: A · The member whose symptoms are seen as the family's problem
Why this is the answer
Family systems theory sees the family as a unit in which each member affects the others. The "identified patient" carries the symptoms, but the therapy looks at patterns in the whole family.
Answer
A · The member whose symptoms are seen as the family's problem
24.Mental health nursing
Answer: D · Discuss the problem openly and involve patients in finding a solution
Why this is the answer
In a therapeutic milieu, the ward environment itself is used for treatment. Shared decision-making in community meetings builds responsibility, social skills and trust.
Answer
D · Discuss the problem openly and involve patients in finding a solution
25.Nursing math & unit conversions
Answer: T = 97.7 °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
36.5·9/5 = 65.7
Add 32
T = 65.7 + 32 = 97.7 °F
Answer
T = 97.7 °F
26.Nursing math & unit conversions
Answer: V = 267.5 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
1½ tbsp = 1.5·15 = 22.5 mL
1 tsp = 1·5 = 5 mL
8 fl oz = 8·30 = 240 mL
Add
V = 22.5 + 5 + 240 = 267.5 mL
Answer
V = 267.5 mL
27.Dosage calculations
Answer: V = 6.8 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 20·17 = 340 mg
Volume
V = 340/50 = 6.8 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 6.8 mL
28.Dosage calculations
Answer: V = 0.54 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Same units
2.16 mg = 2160 mcg
Volume
V = 2160/4000 = 0.54 mL
Answer
V = 0.54 mL
29.IV infusion rates
Answer: V = 2400 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
50·60/15 = 200 mL/h
Volume
V = 200·12 = 2400 mL
Answer
V = 2400 mL
30.IV infusion rates
Answer: R = 120 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
4·60 = 240 mg/h
Pump rate
R = 240/2 = 120 mL/h
Answer
R = 120 mL/h
31.Pediatric & critical-care dosing
Answer: D = 8 units/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.
Concentration
100/100 = 1 units/mL
Units per hour
D = 8·1 = 8 units/h
Answer
D = 8 units/h
32.Pediatric & critical-care dosing
Answer: R = 6.5 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
800 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
2·86 = 172 mcg/min
172·60 = 10320 mcg/h
Pump rate
R = 10320/1600 = 6.45 ≈ 6.5 mL/h
Answer
R = 6.5 mL/h
33.IV fluids & fluid balance
Answer: B = −650 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.
Total intake
oral: 100 + 120 + 150 = 370 mL
IV infusion: 75·8 = 600 mL
IV antibiotic: 2·50 = 100 mL
total intake = 1070 mL
Total output
400 + 500 + 300 + 400 + 120 = 1720 mL
Balance
B = 1070 − 1720 = −650 mL
Answer
B = −650 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: t = 3.6 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 − 50 = 450 mL
Time
t = 450/125 = 3.6 h
Answer
t = 3.6 h
That is about 3 h 36 min, so the bag runs out at about 19:06.
35.Clinical assessment scores
Answer: SI = 0.66
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.
Shock index
SI = 94/143 = 0.6573 ≈ 0.66
Answer
SI = 0.66
Within or below the usual 0.5–0.7.
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 = 79/1.61² = 30.48
Category
obesity class I
Answer
obesity class I
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 30.3 mmol/L
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.
Change in PaCO₂
|58 − 40| = 18 mmHg → 1.8 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·1.8 = 30.3 mmol/L
Answer
HCO₃⁻ = 30.3 mmol/L
38.Arterial blood gas interpretation
Answer: AGc = 19.25 mmol/L
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 = 146 − (111 + 20) = 15
Correction for albumin
15 + 0.25·(40 − 23) = 19.25 mmol/L
Answer
AGc = 19.25 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: QTc = 0.5 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 12.5 × 0.04 = 0.50 s
RR = 25 × 0.04 = 1.00 s
Fridericia’s formula
QTc = 0.50/∛1.00 = 0.50/1 = 0.5 s
Answer
QTc = 0.5 s
Above the usual limits for both men (about 0.45 s) and women (about 0.46 s): prolonged. (500 ms)
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 = 44 small boxes, 1500 ÷ 44 ≈ 34 per minute.
2. Rhythm: regular, every R–R is 1.76 s.
3. P waves: upright and regular (P–P 0.88 s, 68 per minute), two for every QRS.
4. PR interval: constant at 0.16 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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