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 medicine commonly causes constipation?
ACodeine
BLactulose
CSenna
DDocusate
2.Nursing fundamentalsHard
Why must a needlestick injury be reported straight away rather than at the end of the shift?
AThe injury must be documented within ten minutes for the report to be valid
BReporting late means the nurse has to pay for the tests
CPost-exposure prophylaxis works best when it is started as soon as possible
DThe source patient will be discharged soon
3.Infection control & patient safetyMedium
A nurse finds a used needle in a patient’s bed linen. What should the nurse do?
ALeave it where it is for the housekeeping staff to remove later in the day
BRecap it with two hands before throwing it away
CPick it up by the hub or with forceps, put it in a sharps container and report it
DFold it into the linen and send it to the laundry
4.Infection control & patient safetyHard
While preparing an IV medication, a nurse sees that the syringe tip touched the medication tray after the cap came off. What should the nurse do?
AWipe the tip with an alcohol swab and give the dose
BBlow on the tip to remove any dust
CDiscard the syringe and prepare the dose again with new equipment
DGive the dose anyway, because the medication tray was cleaned this morning
5.Prioritization & delegationMedium
A nurse asks a nursing assistant to “assess the patient’s pain and decide if the patient needs more medication”. Which right of delegation is violated?
ARight circumstance
BRight supervision and evaluation
CRight task
DRight person
6.Prioritization & delegationHard
During START triage, a non-walking adult breathes 28 times a minute, has no radial pulse and has a capillary refill of 4 seconds. Which category is the victim given?
ARed (immediate)
BBlack (expectant)
CGreen (minor)
DYellow (delayed), because the respiratory rate is under 30/min
7.Clinical nursingMedium
A patient is having a 12-lead ECG. Where are the chest electrodes placed?
AOn both shoulders and both hips only
BAnywhere on the chest where the skin is clear
CIn standard numbered positions across the front and left of the chest
DIn a straight line down the centre of the sternum from top to bottom
8.Clinical nursingHard
A patient with cirrhosis and a large tense abdomen undergoes paracentesis. Why may albumin be given?
ATo treat infection in the fluid
BTo reduce the risk of circulatory dysfunction after large-volume fluid removal
CTo increase urine potassium
DTo stop the liver making more bile
9.Lab values & electrolytesMedium
How does normal pregnancy usually affect serum creatinine?
AIt falls, because GFR rises
BIt stays exactly the same
CIt rises with every week
DIt rises, because GFR falls
10.Lab values & electrolytesHard
A patient using an insulin pump has a glucose of 300 mg/dL (16.7 mmol/L) that has not fallen 2 hours after a correction bolus through the pump. Blood ketones are 1.8 mmol/L. What is the most likely problem and action?
ARebound after a hypo; give fast-acting carbohydrate and recheck in 15 minutes
BInsulin overdose from the pump; suspend the pump and stop all insulin for a day
CInsulin delivery failure; inject a correction dose by pen and change the set
DNormal pump function; wait for the next mealtime bolus to lower the glucose
11.PharmacologyMedium
A patient starting niacin (nicotinic acid) complains of flushing and warmth after doses. Which advice may reduce this?
ATake it on an empty stomach in a hot bath
BTake the niacin with a hot drink so that it dissolves and acts faster
CTake aspirin 30 minutes before the niacin, if the prescriber agrees
DDouble the dose to build tolerance faster
12.PharmacologyHard
A patient with early aspirin (salicylate) overdose has tinnitus and is breathing fast. Which acid–base pattern is classic?
ARespiratory alkalosis followed by metabolic acidosis
BPure metabolic alkalosis
CMetabolic alkalosis followed by respiratory acidosis
DRespiratory acidosis with normal bicarbonate
13.Med-surg: cardiovascular & respiratoryMedium
Analysis of a pleural effusion shows it is an exudate (high protein and LDH compared with blood). Which cause is most likely?
AHeart failure with raised venous pressure
BNephrotic syndrome with protein lost in urine
CLiver cirrhosis with a low albumin
DPneumonia or cancer affecting the pleura
14.Med-surg: cardiovascular & respiratoryHard
A patient recovering from an MI is anxious about returning to normal life. Which intervention best supports recovery?
AAdvice to rest in bed for three months
BAdvice to stop tablets once they feel well
CReferral to cardiac rehabilitation
DAdvice to avoid all exercise permanently
15.Med-surg: neuro, endocrine & renalMedium
A patient has Cushing's syndrome. Which nursing assessment is especially important?
ARegular blood glucose checks
BChecking for low blood pressure
CMonitoring for a high potassium
DWatching for weight loss
16.Med-surg: neuro, endocrine & renalHard
A patient with CKD has a potassium of 6.5 mmol/L. Which medicine combination is the most likely contributor?
AAmlodipine, simvastatin and aspirin
BRamipril, spironolactone and trimethoprim
CParacetamol (acetaminophen), omeprazole and senna
DFurosemide, salbutamol and insulin
17.Med-surg: GI, perioperative & oncologyMedium
Which medicine commonly delays wound healing?
AVitamin C supplements
BLong-term corticosteroids
CParacetamol
DSaline eye drops
18.Med-surg: GI, perioperative & oncologyHard
A patient with gallstones has a temperature of 39 °C with rigors, jaundice and right upper abdominal pain. What should the nurse suspect?
AAscending cholangitis
BSimple biliary colic
CAcute hepatitis A
DUncomplicated reflux
19.Maternity & obstetric nursingMedium
A woman at 24 weeks reports burning on urination and urinary frequency. What is the priority action?
ACollect a urine sample for culture and inform the provider
BAdvise her to drink less to reduce frequency
CAdvise cranberry juice and no further action
DReassure her that urinary frequency is normal in pregnancy
20.Maternity & obstetric nursingHard
A student nurse is caring for a newborn receiving phototherapy for jaundice. Which action requires correction?
AApplying baby oil to the skin before the lights are switched on
BRemoving the eye shields during feeds when the lights are off
CCovering the baby's eyes with eye shields during phototherapy
DChecking the baby's temperature and hydration regularly
21.Pediatric nursingMedium
What is the purpose of grommets (tympanostomy tubes) in a child with repeated middle ear problems?
ATo widen the outer ear canal and reduce the build-up of wax
BTo replace the damaged eardrum permanently
CTo give antibiotics directly into the inner ear
DTo ventilate the middle ear and let fluid drain
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 back blows and then abdominal thrusts, and call for help
DGive the child water to swallow
23.Mental health nursingMedium
According to Maslow's hierarchy of needs, which patient need should a nurse on a mental health ward address first?
AA patient who wants to improve her self-esteem
BA patient who wants to find a new hobby
CA patient who has not eaten or drunk anything for two days
DA patient who feels lonely and wants more visitors
24.Mental health nursingHard
A patient asks the nurse to pray with her before her ECT. The nurse does not share her religion. What is the most appropriate response?
ATry to persuade her to adopt the nurse's own beliefs
BIgnore the request politely and change the subject to the procedure itself
CRespect the request, join in if comfortable, and offer to call the chaplain
DTell her that religion has no place in hospital care
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 6 ft 3 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
6 ft 3 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes ½ cup of tea, 1½ tsp of cough syrup, 1½ tbsp of liquid supplement, 2 fl oz of juice. Using the equivalents given, find the total oral intake V in mL.
1 cup = 8 fl oz = 240 mL1 tsp = 5 mL1 tbsp = 15 mL1 fl oz = 30 mL
V = mL
27.Dosage calculationsMedium
A child weighing 18 kg is prescribed 5 mg/kg of a drug. The stock solution contains 25 mg/mL. Draw up the dose: what volume V do you give?
18 kg5 mg/kg25 mg/mL
V = mL
28.Dosage calculationsHard
A patient weighs 116.6 lb. The prescription is 10 mg/kg as a single dose, and the stock contains 125 mg in 5 mL. Using 1 kg = 2.2 lb, what volume V do you give?
116.6 lb10 mg/kg125 mg/5 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
1000 mL was ordered over 6 hours. After 3 hours you find that 610 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?
1000 mL / 6 hafter 3 h: 610 mL
R = mL/h
30.IV infusion ratesHard
200 mg of a drug is diluted in 100 mL and given by gravity through a set of 20 gtt/mL. The order is 150 mg per hour. Find the drip rate R in drops per minute.
200 mg/100 mL150 mg/h20 gtt/mL
R = gtt/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 14 units/kg/h for a patient who weighs 96 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL14 units/kg/h96 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 400 mg in 250 mL. The order is 10 mcg/kg/min for a patient who weighs 102 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL10 mcg/kg/min102 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 78 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 11:30 at 75 mL/h. After 2 hours the rate is changed to 200 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL75 mL/h · 2 h200 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 5, with E1 and V2. What motor score M was recorded, and which response does it describe? Give the number.
GCS 5E1V2
M =
36.Clinical assessment scoresHard
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: none, bed rest or nurse assists; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; mental status: overestimates or forgets limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 72 mmHg (9.6 kPa). Use the rule that in acute respiratory acidosis HCO₃⁻ rises by 1 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a metabolic alkalosis with HCO₃⁻ 41 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 41 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
This lead II strip shows sinus rhythm with one pause. Measure the pause, the R–R interval across it, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
pause = s
40.ECG rhythm strip interpretationHard
This lead II strip shows second-degree AV block type I (Wenckebach). By how much does the PR interval increase from the first to the second beat of a group (ΔPR), in seconds?
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ΔPR = s
3Solutions
1.Nursing fundamentals
Answer: A · Codeine
Why this is the answer
Opioids such as codeine and morphine slow gut movement and commonly cause constipation. Senna, lactulose and docusate are laxatives.
Answer
A · Codeine
2.Nursing fundamentals
Answer: C · Post-exposure prophylaxis works best when it is started as soon as possible
Why this is the answer
After a high-risk exposure, for example to HIV or hepatitis B, preventive treatment is most effective when started early. Prompt reporting also allows the source patient to be assessed.
Answer
C · Post-exposure prophylaxis works best when it is started as soon as possible
3.Infection control & patient safety
Answer: C · Pick it up by the hub or with forceps, put it in a sharps container and report it
Why this is the answer
A loose needle is a hazard to everyone who handles the linen. The nurse disposes of it safely without recapping, using an instrument if needed, and reports the incident so the cause can be addressed.
Answer
C · Pick it up by the hub or with forceps, put it in a sharps container and report it
4.Infection control & patient safety
Answer: C · Discard the syringe and prepare the dose again with new equipment
Why this is the answer
In aseptic non-touch technique, key parts such as syringe tips and IV hubs must not touch any non-sterile surface. A contaminated key part is not cleaned and reused. It is replaced.
Answer
C · Discard the syringe and prepare the dose again with new equipment
5.Prioritization & delegation
Answer: C · Right task
Why this is the answer
Assessing a patient and deciding on treatment need nursing judgement, so the task itself cannot be delegated to assistive personnel. An assistant can report what the patient says, but the RN assesses and decides.
Answer
C · Right task
6.Prioritization & delegation
Answer: A · Red (immediate)
Why this is the answer
A rate under 30/min passes the breathing check, but an absent radial pulse or a capillary refill over 2 seconds fails the perfusion check, so the victim is immediate (red). Stopping after the breathing check is the trap.
Answer
A · Red (immediate)
7.Clinical nursing
Answer: C · In standard numbered positions across the front and left of the chest
Why this is the answer
The six chest leads (V1–V6) have standard anatomical positions, from the 4th intercostal space beside the sternum to the mid-axillary line. Wrong placement can change the ECG and lead to misinterpretation.
Answer
C · In standard numbered positions across the front and left of the chest
8.Clinical nursing
Answer: B · To reduce the risk of circulatory dysfunction after large-volume fluid removal
Why this is the answer
Large-volume paracentesis can cause hypotension and renal impairment. Albumin infusion helps maintain the circulating volume.
Answer
B · To reduce the risk of circulatory dysfunction after large-volume fluid removal
9.Lab values & electrolytes
Answer: A · It falls, because GFR rises
Why this is the answer
In pregnancy, kidney blood flow and GFR rise by about 50%, so creatinine falls below non-pregnant values. A creatinine that looks "normal" for a non-pregnant adult may indicate reduced kidney function in pregnancy.
Answer
A · It falls, because GFR rises
10.Lab values & electrolytes
Answer: C · Insulin delivery failure; inject a correction dose by pen and change the set
Why this is the answer
A high glucose that does not respond to a pump bolus, with rising ketones, suggests a kinked, blocked or dislodged cannula. Because pumps use only rapid-acting insulin, DKA can develop within hours. The usual advice is to give a correction dose by pen or syringe, change the infusion set, check glucose and ketones often, and seek help if ketones keep rising or vomiting starts.
Answer
C · Insulin delivery failure; inject a correction dose by pen and change the set
11.Pharmacology
Answer: C · Take aspirin 30 minutes before the niacin, if the prescriber agrees
Why this is the answer
Niacin causes prostaglandin-mediated vasodilation and flushing. Aspirin beforehand, taking it with food and avoiding hot drinks and alcohol reduce this effect.
Answer
C · Take aspirin 30 minutes before the niacin, if the prescriber agrees
12.Pharmacology
Answer: A · Respiratory alkalosis followed by metabolic acidosis
Why this is the answer
Salicylates stimulate breathing, causing respiratory alkalosis early. They then disturb cell metabolism, causing a metabolic acidosis with a raised anion gap. Adults often show a mixed picture.
Answer
A · Respiratory alkalosis followed by metabolic acidosis
13.Med-surg: cardiovascular & respiratory
Answer: D · Pneumonia or cancer affecting the pleura
Why this is the answer
Transudates form when hydrostatic or oncotic pressure changes push fluid out of vessels, as in heart failure, cirrhosis and nephrotic syndrome. Exudates form when inflammation or tumour makes the pleura leaky, so protein and LDH are high (Light's criteria). Common causes are pneumonia, cancer, TB and pulmonary embolism.
Answer
D · Pneumonia or cancer affecting the pleura
14.Med-surg: cardiovascular & respiratory
Answer: C · Referral to cardiac rehabilitation
Why this is the answer
Cardiac rehabilitation combines supervised exercise, risk factor education, medication advice and psychological support. It improves quality of life and reduces cardiovascular mortality and readmissions. Patients are encouraged to return gradually to activity, including work, driving and sex, according to advice.
Answer
C · Referral to cardiac rehabilitation
15.Med-surg: neuro, endocrine & renal
Answer: A · Regular blood glucose checks
Why this is the answer
Cortisol raises blood glucose, so hyperglycaemia and diabetes are common. Hypertension, hypokalaemia, infection and fragile skin are other problems to watch for.
Answer
A · Regular blood glucose checks
16.Med-surg: neuro, endocrine & renal
Answer: B · Ramipril, spironolactone and trimethoprim
Why this is the answer
ACE inhibitors and spironolactone reduce aldosterone effect, and trimethoprim blocks potassium secretion in the distal tubule. Together, in CKD, they can cause dangerous hyperkalaemia. Loop diuretics, salbutamol and insulin lower potassium.
Answer
B · Ramipril, spironolactone and trimethoprim
17.Med-surg: GI, perioperative & oncology
Answer: B · Long-term corticosteroids
Why this is the answer
Corticosteroids suppress the inflammatory phase, collagen formation and immunity, delaying healing and raising infection risk. Other factors include diabetes, smoking, malnutrition, poor perfusion and chemotherapy.
Answer
B · Long-term corticosteroids
18.Med-surg: GI, perioperative & oncology
Answer: A · Ascending cholangitis
Why this is the answer
Fever, jaundice and right upper quadrant pain suggest infection of an obstructed bile duct. It can rapidly cause sepsis and needs blood cultures, IV antibiotics, fluids and urgent biliary drainage, usually by ERCP.
Answer
A · Ascending cholangitis
19.Maternity & obstetric nursing
Answer: A · Collect a urine sample for culture and inform the provider
Why this is the answer
Dysuria suggests a urinary tract infection, which needs culture and treatment with a pregnancy-safe antibiotic. Untreated UTIs can progress to pyelonephritis and preterm labour.
Answer
A · Collect a urine sample for culture and inform the provider
20.Maternity & obstetric nursing
Answer: A · Applying baby oil to the skin before the lights are switched on
Why this is the answer
Oils and lotions can cause burns under phototherapy lights and should not be applied. Eye shields protect the retina, temperature and hydration are monitored because of increased fluid loss, and feeds are an opportunity for eye contact without the shields.
Answer
A · Applying baby oil to the skin before the lights are switched on
21.Pediatric nursing
Answer: D · To ventilate the middle ear and let fluid drain
Why this is the answer
Grommets are small tubes placed in the eardrum that equalise pressure and let fluid drain from the middle ear, improving hearing. They usually fall out by themselves as the eardrum heals.
Answer
D · To ventilate the middle ear and let fluid drain
22.Pediatric nursing
Answer: C · 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
C · Give back blows and then abdominal thrusts, and call for help
23.Mental health nursing
Answer: C · A patient who has not eaten or drunk anything for two days
Why this is the answer
Maslow places physiological needs, such as food and fluids, before safety, love and belonging, esteem and self-actualisation. A patient who is not eating or drinking has the most basic unmet need.
Answer
C · A patient who has not eaten or drunk anything for two days
24.Mental health nursing
Answer: C · Respect the request, join in if comfortable, and offer to call the chaplain
Why this is the answer
Supporting spiritual needs can reduce distress. The nurse can respond with respect within her own comfort, and refer to chaplaincy or faith leaders, without imposing her own beliefs.
Answer
C · Respect the request, join in if comfortable, and offer to call the chaplain
25.Nursing math & unit conversions
Answer: h = 191 cm
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.
Height in inches
6·12 + 3 = 75 in
Inches to centimetres
h = 75·2.54 = 190.5 ≈ 191 cm
Answer
h = 191 cm
26.Nursing math & unit conversions
Answer: V = 210 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
½ cup = 0.5·240 = 120 mL
1½ tsp = 1.5·5 = 7.5 mL
1½ tbsp = 1.5·15 = 22.5 mL
2 fl oz = 2·30 = 60 mL
Add
V = 120 + 7.5 + 22.5 + 60 = 210 mL
Answer
V = 210 mL
27.Dosage calculations
Answer: V = 3.6 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 = 5·18 = 90 mg
Volume
V = 90/25 = 3.6 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 3.6 mL
28.Dosage calculations
Answer: V = 21.2 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.
Weight in kg
116.6/2.2 = 53 kg
Dose
10·53 = 530 mg
Volume
V = (530/125)·5 = 21.2 mL
Answer
V = 21.2 mL
29.IV infusion rates
Answer: R = 203.3 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
1000/6 = 166.7 mL/h
New rate
R = 610/3 = 203.3 mL/h
Answer
R = 203.3 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: R = 25 gtt/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
200/100 = 2 mg/mL
Volume per hour
150/2 = 75 mL/h
Drip rate
R = 75·20/60 = 25 gtt/min
Answer
R = 25 gtt/min
31.Pediatric & critical-care dosing
Answer: R = 33.6 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
14·96 = 1 344 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1344/40 = 33.6 mL/h
Answer
R = 33.6 mL/h
32.Pediatric & critical-care dosing
Answer: R = 38.3 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
400 mg = 400 000 mcg
400 000/250 = 1600 mcg/mL
Dose per minute and per hour
10·102 = 1020 mcg/min
1020·60 = 61200 mcg/h
Pump rate
R = 61200/1600 = 38.25 ≈ 38.3 mL/h
Answer
R = 38.3 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
225 + 450 + 250 = 925 mL
Per kilogram per hour
U = 925/(78·8) = 1.482 ≈ 1.48 mL/kg/h
Answer
U = 1.48 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 3.8 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
75·2 = 150 mL
500 − 150 = 350 mL left
Second part
350/200 = 1.75 h
Total time
t = 2 + 1.75 = 3.75 ≈ 3.8 h
Answer
t = 3.8 h
That is about 3 h 45 min, so the bag runs out at about 15:15.
35.Clinical assessment scores
Answer: M = 2
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.
Motor score
M = 5 − 1 − 2 = 2
M2: extension of the arms and legs (abnormal extension)
Answer
M = 2
36.Clinical assessment scores
Answer: moderate risk
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: none, bed rest or nurse assists → 0
IV therapy or saline lock: yes → 20
gait: normal, bed rest or wheelchair → 0
mental status: overestimates or forgets limits → 15
Add
Morse total = 0 + 0 + 0 + 20 + 0 + 15 = 35
Risk level
35 → moderate risk
Answer
moderate risk
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 27.2 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
|72 − 40| = 32 mmHg → 3.2 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 1·3.2 = 27.2 mmol/L
Answer
HCO₃⁻ = 27.2 mmol/L
38.Arterial blood gas interpretation
Answer: PaCO₂ = 49.7 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
0.7·41 + 21 = 49.7 mmHg
Answer
PaCO₂ = 49.7 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: pause = 2.12 s
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).
Measure
53 small boxes from R to R across the pause
Convert
pause = 53 × 0.04 s = 2.12 s
Compare with P–P
2.12 ÷ 0.88 ≈ 2.4 P–P cycles, not a whole number
Answer
pause = 2.12 s
No P wave appears in the pause, and the pause is not a whole number of P–P cycles: sinus arrest. A pause of exactly two or three cycles would point to sinus exit block.
40.ECG rhythm strip interpretation
Answer: ΔPR = 0.14 s
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.
March out the P waves
P–P = 0.88 s, regular; one P wave in every 3 is not conducted
PR in each group
PR₁ = 0.16 s, PR₂ = 0.30 s
Answer
ΔPR = 0.14 s
The biggest step in PR comes between the first and second beats of a group; later steps are smaller, which is why the R–R intervals shorten before the pause.
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