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
A smoker says, "I know I should stop, and I'm thinking about it some time in the next few months." Which stage of change is this?
APrecontemplation
BMaintenance
CContemplation
DPreparation
2.Nursing fundamentalsHard
Why is the level of sedation a useful early warning in a patient on opioids?
AIncreasing sedation usually comes before respiratory depression
BSedation means the opioid dose is too low
CSedation only occurs after the breathing has stopped
DSedation shows that the pain has completely gone and the dose is right
3.Infection control & patient safetyMedium
A patient has botulism after eating contaminated food. Which precautions are needed?
ADroplet precautions
BStandard precautions
CContact precautions
DAirborne precautions
4.Infection control & patient safetyHard
A nurse floated to an unfamiliar unit is asked to manage a device they have never been trained to use. What should the nurse do?
AAsk the patient or the family to explain how the device works
BLeave the device untouched and not tell anyone
CDo it anyway, using only the device manual and the instructions on the screen
DTell the charge nurse and ask for help or a change of assignment
5.Prioritization & delegationMedium
A registered nurse tells a nursing assistant, “Check on the patient in room 12.” Which right of delegation is missing?
ARight directions and communication
BRight circumstance
CRight person for the task
DRight task for the setting
6.Prioritization & delegationHard
Which patient is the most appropriate to assign to an LPN/LVN?
AA patient with a tracheostomy placed this morning who is coughing up blood
BA patient with a long-standing tracheostomy who needs routine suctioning and care
CA patient on a new IV medication that needs frequent titration
DA patient who has just arrived from the emergency department with pneumonia and confusion
7.Clinical nursingMedium
Which electrolyte disturbance is most dangerous for the heart rhythm?
ALow sodium
BHigh or low potassium
CLow phosphate
DHigh chloride
8.Clinical nursingHard
A patient's urine output has been very low for 12 hours and creatinine has risen sharply. Which drug on the chart is most likely to need review?
AA vitamin supplement
BAn emollient cream
CA non-steroidal anti-inflammatory drug such as ibuprofen
DParacetamol at usual doses
9.Lab values & electrolytesMedium
A patient with diabetes is found unconscious with a blood glucose of 38 mg/dL (2.1 mmol/L). Which treatment is appropriate?
AGlucagon by injection, or IV dextrose as prescribed
BOrange juice poured slowly into the patient's mouth
CA dose of rapid-acting insulin to stabilize the glucose
DGlucose tablets placed between the patient's teeth
10.Lab values & electrolytesHard
During surgery under general anesthesia, a patient develops a rising end-tidal CO2, muscle rigidity and tachycardia, then a high potassium and a rising temperature. Which condition is most likely?
AMalignant hyperthermia
BAcute hemolytic transfusion reaction
CHypoglycemia from fasting
DHypovolemic shock
11.PharmacologyMedium
Which adverse effect of doxorubicin requires monitoring of heart function?
APericarditis caused by infection
BCumulative heart muscle damage leading to heart failure
CRapid rise in cholesterol
DSevere hypertension during the infusion itself
12.PharmacologyHard
A patient who has had several courses of bleomycin develops a dry cough and worsening breathlessness. What should the nurse suspect?
AHeart failure from bleomycin
BAsthma caused by anxiety
CA normal effect that will pass in a day
DPulmonary fibrosis from bleomycin
13.Med-surg: cardiovascular & respiratoryMedium
What is the main problem in heart failure with preserved ejection fraction?
AA dilated ventricle that cannot contract strongly
BA blocked pulmonary artery
CA leaking aortic valve
DA stiff ventricle that fills poorly in diastole
14.Med-surg: cardiovascular & respiratoryHard
After hip surgery, a patient suddenly becomes breathless and anxious with a heart rate of 124/min, SpO₂ 86% on air and sharp pain on breathing. The chest sounds clear. What should the nurse do first?
AWalk the patient round the ward to improve breathing
BLie the patient flat and raise both legs on pillows
CGive oxygen, sit them up, call for urgent review and stay
DGive a sedative for the anxiety and recheck in an hour
15.Med-surg: neuro, endocrine & renalMedium
When the nurse squeezes the trapezius muscle, the patient brings a hand up above the collarbone towards the stimulus. Which GCS motor score is this?
A6, obeys commands
B4, withdraws from pain
C3, abnormal flexion
D5, localises to pain
16.Med-surg: neuro, endocrine & renalHard
Three days after a stroke, a patient with dysphagia on a modified diet has a temperature of 38.2 °C (100.8 °F), a respiratory rate of 24/min and crackles at the right lung base. What should the nurse do?
AGive paracetamol (acetaminophen) and continue the modified diet as before
BRecord the findings and recheck them at the next routine observation
CEncourage more fluids by mouth to treat the fever
DSuspect aspiration pneumonia, stop oral intake and escalate for review
17.Med-surg: GI, perioperative & oncologyMedium
Why is the "whoosh" test no longer used to check nasogastric tube position?
AThe test is far too painful for most patients to tolerate
BThe air always makes the tube block
CAir can be heard even when the tube is in the lung
DIt needs an X-ray machine at the bedside
18.Med-surg: GI, perioperative & oncologyHard
A patient with gastric outlet obstruction has vomited repeatedly for several days. Which blood picture is most likely?
AHigh chloride, high potassium and metabolic acidosis
BLow chloride, low potassium and metabolic alkalosis
CNormal electrolytes with respiratory alkalosis
DHigh calcium, high sodium and respiratory acidosis
19.Maternity & obstetric nursingMedium
The fundus is boggy, above the umbilicus and displaced to the right. What is the most likely cause?
AA full bladder
BA normal finding on day 1
CA tear in the perineum
DRetained placental tissue on the left
20.Maternity & obstetric nursingHard
A large for gestational age newborn of a mother with diabetes is also very red and has a high haematocrit. Which complication of this finding should the nurse watch for?
AHypothermia caused by sweating
BJaundice
CDehydration caused by vomiting
DNeural tube defects
21.Pediatric nursingMedium
What should the nurse do before giving a dose of digoxin to an infant?
ACount the radial pulse for 15 seconds and multiply by four
BCount the apical pulse for a full minute and check it against the prescribed limits
CMeasure the temperature and give the dose only if there is no fever
DMeasure the blood pressure and give the dose only if it is above the normal range
22.Pediatric nursingHard
A 15-year-old with type 1 diabetes has lost weight, and her HbA1c has risen sharply. She admits to skipping insulin doses. What should the nurse consider?
AThe glucose meter must be broken
BShe simply needs a lower insulin dose
CWeight loss is a good sign of improved control, so her insulin dose can now be lowered further
DShe may be omitting insulin to lose weight, a form of disordered eating that needs assessment
23.Mental health nursingMedium
An 84-year-old asks for an over-the-counter sleep aid containing diphenhydramine. What is the main concern?
AIt raises blood pressure to dangerous levels in older adults
BIts anticholinergic effects can cause confusion, urine retention and falls
CIt is a strong opioid that causes severe dependence
DIt has no effects at all in people over 80, so it will not help her sleep
24.Mental health nursingHard
A patient in a manic episode starts taking off her clothes in the busy day room. What is the most appropriate action?
ACall security to remove her from the ward
BAsk the other patients to ignore her and carry on
CTell her loudly in front of everyone that she must stop
DCalmly cover her and guide her to her room or a quiet area
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A weight conversion gives 95.3877 kg. The rule in this exercise is that weights are rounded to the nearest tenth of a kilogram. What value x do you record?
95.3877 kg
x = kg
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A maintenance infusion runs at 50 mL/h without a break. How many litres V does it deliver in 24 hours?
50 mL/h24 h
V = L
27.Dosage calculationsMedium
A patient weighs 18 kg and is prescribed 25 mg/kg as a single dose. Find the dose D in mg.
18 kg25 mg/kg
D = mg
28.Dosage calculationsHard
A child weighing 10 kg is prescribed 10 mg/kg per dose of an oral suspension that contains 40 mg in 1 mL. What volume V do you give?
10 kg10 mg/kg40 mg/1 mL
V = mL
29.IV infusion ratesMedium
500 mL was ordered over 6 hours. After 2 hours you find that 400 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
500 mL / 6 hafter 2 h: 400 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 500 mg of a drug in 100 mL and runs at 10 mL/h. How many milligrams per hour D does the patient receive?
500 mg/100 mL10 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 15 units/kg/h for a patient who weighs 105 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL15 units/kg/h105 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dobutamine 500 mg in 250 mL. The order is 7.5 mcg/kg/min for a patient who weighs 103 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
500 mg/250 mL7.5 mcg/kg/min103 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 75 mL/h. At 17:30, 100 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL100 mL infused75 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: no; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: no; gait: normal, bed rest or wheelchair; mental status: overestimates or forgets limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 92 kg and is 169 cm tall. Calculate the BMI and click the WHO weight category.
92 kg169 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 16 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 16 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 136, Cl⁻ 114, HCO₃⁻ 14 mmol/L and albumin 18 g/L. Find the albumin-corrected anion gap AGc = AG + 0.25·(40 − albumin).
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
1atrial flutter, 4:1 conduction
2sinus tachycardia
3normal sinus rhythm
4atrial flutter, 3:1 conduction
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1third-degree (complete) AV block
2ventricular paced rhythm
3sinus rhythm with wide QRS
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: C · Contemplation
Why this is the answer
In the stages-of-change model, contemplation means considering change within about six months without a firm plan. Precontemplation means not thinking about change yet.
Answer
C · Contemplation
2.Nursing fundamentals
Answer: A · Increasing sedation usually comes before respiratory depression
Why this is the answer
Patients usually become drowsy before their breathing slows dangerously. Checking sedation with a simple scale alongside respiratory rate allows early action.
Answer
A · Increasing sedation usually comes before respiratory depression
3.Infection control & patient safety
Answer: B · Standard precautions
Why this is the answer
Botulism is caused by a toxin and does not spread from person to person, so standard precautions are used. Suspected cases are reported to public health at once.
Answer
B · Standard precautions
4.Infection control & patient safety
Answer: D · Tell the charge nurse and ask for help or a change of assignment
Why this is the answer
Accepting a task beyond one’s competence puts the patient at risk. The nurse explains the limit to the charge nurse, who can arrange help, training or reassignment.
Answer
D · Tell the charge nurse and ask for help or a change of assignment
5.Prioritization & delegation
Answer: A · Right directions and communication
Why this is the answer
“Check on” does not say what to measure, when, or which findings to report. A clear instruction would be, for example, “Measure his blood pressure and pulse at 10:00 and tell me at once if the systolic is below 100.”
Answer
A · Right directions and communication
6.Prioritization & delegation
Answer: B · A patient with a long-standing tracheostomy who needs routine suctioning and care
Why this is the answer
Routine tracheostomy care for a stable, long-term patient fits the LPN/LVN role in most settings. Fresh or bleeding tracheostomies, new admissions and titrated IV drugs need RN assessment.
Answer
B · A patient with a long-standing tracheostomy who needs routine suctioning and care
7.Clinical nursing
Answer: B · High or low potassium
Why this is the answer
Both hyperkalaemia and hypokalaemia can cause life-threatening arrhythmias. Potassium must never be given as an undiluted rapid IV bolus.
Answer
B · High or low potassium
8.Clinical nursing
Answer: C · A non-steroidal anti-inflammatory drug such as ibuprofen
Why this is the answer
In acute kidney injury, nephrotoxic drugs (such as NSAIDs and aminoglycosides) and drugs that reduce renal perfusion (such as ACE inhibitors and diuretics) are reviewed and often stopped.
Answer
C · A non-steroidal anti-inflammatory drug such as ibuprofen
9.Lab values & electrolytes
Answer: A · Glucagon by injection, or IV dextrose as prescribed
Why this is the answer
A patient who cannot swallow safely must not receive anything by mouth because of the risk of aspiration. Glucagon (injected or intranasal) or IV dextrose raises the glucose; once awake and able to swallow, the patient is given oral carbohydrate and a snack.Checked against:Hypoglycemia · MedlinePlus (NIH); Low blood sugar · MedlinePlus (NIH) (2026)
Answer
A · Glucagon by injection, or IV dextrose as prescribed
10.Lab values & electrolytes
Answer: A · Malignant hyperthermia
Why this is the answer
Malignant hyperthermia is a genetic hypermetabolic reaction to volatile anesthetics or succinylcholine. Muscle cells release calcium, producing CO2, heat, rigidity, hyperkalemia and very high CK. It is treated with dantrolene and stopping the trigger.
Answer
A · Malignant hyperthermia
11.Pharmacology
Answer: B · Cumulative heart muscle damage leading to heart failure
Why this is the answer
Anthracyclines such as doxorubicin can damage heart muscle, and the risk increases with cumulative dose. Heart function is assessed before and during treatment; the drug can also turn urine red.
Answer
B · Cumulative heart muscle damage leading to heart failure
12.Pharmacology
Answer: D · Pulmonary fibrosis from bleomycin
Why this is the answer
Bleomycin can cause pneumonitis and pulmonary fibrosis, especially at higher cumulative doses. New respiratory symptoms are reported, and lung function may be monitored.
Answer
D · Pulmonary fibrosis from bleomycin
13.Med-surg: cardiovascular & respiratory
Answer: D · A stiff ventricle that fills poorly in diastole
Why this is the answer
In HFpEF, the left ventricle is stiff and relaxes poorly, so filling pressures rise and cause congestion even though the ejection fraction is normal. It is common in older people with hypertension, diabetes and obesity. HFrEF is mainly a problem of contraction.
Answer
D · A stiff ventricle that fills poorly in diastole
14.Med-surg: cardiovascular & respiratory
Answer: C · Give oxygen, sit them up, call for urgent review and stay
Why this is the answer
Sudden breathlessness, tachycardia, pleuritic pain and hypoxaemia after orthopaedic surgery suggest pulmonary embolism. Immediate actions are supportive: oxygen to target saturation, upright positioning if blood pressure allows, urgent escalation and continuous monitoring, followed by investigations and anticoagulation as prescribed. Sedation could mask deterioration and depress breathing.
Answer
C · Give oxygen, sit them up, call for urgent review and stay
15.Med-surg: neuro, endocrine & renal
Answer: D · 5, localises to pain
Why this is the answer
Localising to pain (5) means a purposeful movement towards the source of pain. Withdrawal (4) is pulling away, abnormal flexion (3) is decorticate posturing, and obeying commands (6) needs no pain at all. A central stimulus, such as a trapezius squeeze, is used to test for localising.
Answer
D · 5, localises to pain
16.Med-surg: neuro, endocrine & renal
Answer: D · Suspect aspiration pneumonia, stop oral intake and escalate for review
Why this is the answer
These signs suggest aspiration pneumonia, which is a common and serious complication of dysphagia. The patient needs medical review, chest assessment, oxygen if needed, and reassessment of their swallow before eating again.
Answer
D · Suspect aspiration pneumonia, stop oral intake and escalate for review
17.Med-surg: GI, perioperative & oncology
Answer: C · Air can be heard even when the tube is in the lung
Why this is the answer
Auscultation of injected air cannot distinguish the stomach from the lungs or oesophagus, and misplaced tubes have caused deaths. pH testing of aspirate or X-ray is used instead.
Answer
C · Air can be heard even when the tube is in the lung
18.Med-surg: GI, perioperative & oncology
Answer: B · Low chloride, low potassium and metabolic alkalosis
Why this is the answer
Loss of gastric acid causes a hypochloraemic metabolic alkalosis. Hypokalaemia follows from vomiting and kidney potassium loss as the body tries to save volume. Treatment includes IV saline with potassium.
Answer
B · Low chloride, low potassium and metabolic alkalosis
19.Maternity & obstetric nursing
Answer: A · A full bladder
Why this is the answer
A full bladder lifts and displaces the uterus, usually to the right, and stops it contracting well. Helping the woman to empty her bladder usually lets the fundus return to the midline and firm up.
Answer
A · A full bladder
20.Maternity & obstetric nursing
Answer: B · Jaundice
Why this is the answer
Polycythaemia is common in infants of diabetic mothers and SGA babies. Breakdown of the extra red cells raises bilirubin, and high viscosity can cause poor feeding, lethargy or thrombosis.
Answer
B · Jaundice
21.Pediatric nursing
Answer: B · Count the apical pulse for a full minute and check it against the prescribed limits
Why this is the answer
Digoxin slows the heart rate and has a narrow therapeutic range. The apical pulse is counted for a full minute before each dose, and the dose is withheld and reported if the rate is below the limit set by the prescriber or local policy.
Answer
B · Count the apical pulse for a full minute and check it against the prescribed limits
22.Pediatric nursing
Answer: D · She may be omitting insulin to lose weight, a form of disordered eating that needs assessment
Why this is the answer
Deliberate insulin omission for weight loss is a recognised eating disorder behaviour in young people with type 1 diabetes. It raises the risk of DKA and complications and needs sensitive assessment and referral.
Answer
D · She may be omitting insulin to lose weight, a form of disordered eating that needs assessment
23.Mental health nursing
Answer: B · Its anticholinergic effects can cause confusion, urine retention and falls
Why this is the answer
Diphenhydramine is strongly anticholinergic and sedating. In older adults, it can cause delirium, constipation, urinary retention and falls, and is generally avoided.
Answer
B · Its anticholinergic effects can cause confusion, urine retention and falls
24.Mental health nursing
Answer: D · Calmly cover her and guide her to her room or a quiet area
Why this is the answer
Disinhibition in mania can lead to embarrassment and exploitation. The nurse protects her privacy and dignity quietly and moves her to a less stimulating environment.
Answer
D · Calmly cover her and guide her to her room or a quiet area
25.Nursing math & unit conversions
Answer: x = 95.4 kg
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the tenths place
95.3877 → 3
Only the next digit decides
95.3877 → 8
8 is 5 or more, so round 3 up.
The digits after it (77) are ignored: round once, never step by step.
Round
x = 95.4 kg
Answer
x = 95.4 kg
26.Nursing math & unit conversions
Answer: V = 1.2 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.
Volume in a day
50 mL/h × 24 h = 1200 mL
In litres
V = 1200/1000 = 1.2 L
Answer
V = 1.2 L
27.Dosage calculations
Answer: D = 450 mg
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.
Dose
25·18 = 450 mg
Answer
D = 450 mg
28.Dosage calculations
Answer: V = 2.5 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.
Dose from weight
10·10 = 100 mg
Volume
V = (100/40)·1 = 2.5 mL
Answer
V = 2.5 mL
29.IV infusion rates
Answer: R = 100 mL/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
500/6 = 83.33 mL/h
New rate
R = 400/4 = 100 mL/h
Answer
R = 100 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: D = 50 mg/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Concentration
500/100 = 5 mg/mL
Dose rate
D = 5·10 = 50 mg/h
Answer
D = 50 mg/h
31.Pediatric & critical-care dosing
Answer: R = 15.8 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
15·105 = 1 575 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1575/100 = 15.75 ≈ 15.8 mL/h
Answer
R = 15.8 mL/h
32.Pediatric & critical-care dosing
Answer: R = 23.2 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
500 mg = 500 000 mcg
500 000/250 = 2000 mcg/mL
Dose per minute and per hour
7.5·103 = 772.5 mcg/min
772.5·60 = 46350 mcg/h
Pump rate
R = 46350/2000 = 23.18 ≈ 23.2 mL/h
Answer
R = 23.2 mL/h
33.IV fluids & fluid balance
Answer: B = −375 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 + 180 + 100 = 380 mL
IV infusion: 50·8 = 400 mL
IV antibiotic: 2·100 = 200 mL
total intake = 980 mL
Total output
225 + 350 + 175 + 275 + 80 + 250 = 1355 mL
Balance
B = 980 − 1355 = −375 mL
Answer
B = −375 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: t = 5.3 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 − 100 = 400 mL
Time
t = 400/75 = 5.333 ≈ 5.3 h
Answer
t = 5.3 h
That is about 5 h 20 min, so the bag runs out at about 22:50.
35.Clinical assessment scores
Answer: MFS = 30
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: no → 0
secondary diagnosis: no → 0
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: no → 0
gait: normal, bed rest or wheelchair → 0
mental status: overestimates or forgets limits → 15
Add
Morse total = 0 + 0 + 15 + 0 + 0 + 15 = 30
Answer
MFS = 30
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 = 92/1.69² = 32.21
Category
obesity class I
Answer
obesity class I
37.Arterial blood gas interpretation
Answer: PaCO₂ = 32 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 = 1.5·16 + 8 = 32 mmHg
range: 30–34 mmHg
Answer
PaCO₂ = 32 mmHg
38.Arterial blood gas interpretation
Answer: AGc = 13.5 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 = 136 − (114 + 14) = 8
Correction for albumin
8 + 0.25·(40 − 18) = 13.5 mmol/L
Answer
AGc = 13.5 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: atrial flutter, 4:1 conduction
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: R–R = 20 small boxes, 1500 ÷ 20 ≈ 75 per minute.
2. Rhythm: regular, every R–R is 0.80 s.
3. P waves: none; regular sawtooth flutter waves every 0.20 s (300 per minute), 4 for each QRS.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
atrial flutter, 4:1 conduction
Answer
atrial flutter, 4:1 conduction
40.ECG rhythm strip interpretation
Answer: ventricular paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 22 small boxes, 1500 ÷ 22 ≈ 68 per minute.
2. Rhythm: regular, every R–R is 0.88 s.
3. P waves: none visible; a sharp pacing spike comes just before every QRS.
4. PR interval: not measurable.
5. QRS: 0.16 s, wide, and every spike is followed by a QRS (capture).
Interpretation
ventricular paced rhythm
Answer
ventricular paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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