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 combination of signs suggests a wound infection?
AA dry scab with no pain
BIncreasing redness, warmth, swelling, pain and pus
CPink granulation tissue, mild serous fluid and a shrinking wound
DMild itching as the edges close
2.Nursing fundamentalsHard
During medicines reconciliation, the patient says they take an anticoagulant at home, but it has not been prescribed in hospital. What should the nurse do?
ATell the patient to stop it for good
BGive the patient's own supply without telling anyone
CIgnore it, as the hospital doctor knows best
DInform the prescriber so the omission can be reviewed
3.Infection control & patient safetyMedium
A patient with a severe latex allergy is booked for surgery. Which measure is commonly used?
AGive the patient antihistamines before surgery and then use the normal supplies
BUse latex gloves only for short procedures
CWrap latex items in plastic before use
DUse latex-free supplies and schedule the patient as the first case of the day
4.Infection control & patient safetyHard
A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?
A“We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
B“We will not smoke near the baby.”
C“We will lay the baby on the back for every sleep, including naps.”
D“We will keep the crib in our room, next to our bed, for the first months.”
5.Prioritization & delegationMedium
A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?
A“I will wait until tomorrow morning to see if the reading gets better on its own.”
B“I will use my reliever inhaler and get emergency help straight away.”
C“I will stop all my inhalers until the reading is back up.”
D“I will go for a short run to open up my lungs.”
6.Prioritization & delegationHard
A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?
AHelping the patient to walk in the corridor alone
BSeizure precautions and close neurological checks
CTeaching the patient about a low-sodium diet at home
DEncouraging the patient to drink plenty of water
7.Clinical nursingMedium
An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?
ADiverticulitis
BAppendicitis
CBiliary colic
DGastric ulcer
8.Clinical nursingHard
A patient with a possible neck injury after a fall needs their airway opened. Which manoeuvre is preferred?
AHead tilt with chin lift
BHyperextending the neck
CJaw thrust
DTurning the head to one side
9.Lab values & electrolytesMedium
A patient on warfarin for atrial fibrillation has a target INR of 2.0–3.0. How does the usual target for a patient with a mechanical mitral valve compare?
AMuch higher, about 5.0–6.0
BHigher, about 2.5–3.5
CLower, about 1.0–1.5
DThe same, 2.0–3.0
10.Lab values & electrolytesHard
A patient with sepsis has the following new results. Which set best shows organ dysfunction?
What should the nurse teach a patient about taking levothyroxine?
ATake it on an empty stomach, 30–60 minutes before breakfast
BTake it together with the iron tablet to save time
CTake it only on days when feeling tired
DTake it with milk at dinner, as calcium protects the stomach lining
12.PharmacologyHard
Why is gentamicin dosing monitored with blood levels?
AIt is metabolised entirely by the liver, so liver function decides the dose
BIt causes severe hypoglycaemia
CIt is nephrotoxic and ototoxic with a narrow therapeutic index
DIt only works at very high concentrations
13.Med-surg: cardiovascular & respiratoryMedium
A patient has a raised B-type natriuretic peptide (BNP or NT-proBNP). What does this mainly reflect?
AStretch and pressure overload of the ventricles
BInflammation of the liver from congestion
CIschaemic damage to the heart muscle
DDamage to skeletal muscle after a fall
14.Med-surg: cardiovascular & respiratoryHard
A patient with COPD on a 28% Venturi mask (SpO₂ 90%) wants to eat a meal. What is the most appropriate plan?
AChange to a non-rebreather mask at 15 L/min during the meal
BRemove all oxygen during the meal and replace it afterwards
CKeep the Venturi mask on and give only liquids through a straw
DSwitch to nasal cannula at low flow, keeping SpO₂ at 88–92%
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?
A3, abnormal flexion
B5, localises to pain
C6, obeys commands
D4, withdraws from pain
16.Med-surg: neuro, endocrine & renalHard
A patient with multiple sclerosis has had worse leg weakness for one day, together with a fever and burning on passing urine. What is the most likely explanation?
AA change to progressive MS
BA pseudo-relapse caused by infection
CA true relapse that needs high-dose steroids
DA side effect of physiotherapy
17.Med-surg: GI, perioperative & oncologyMedium
Which practice is correct when giving parenteral nutrition through a central line?
ALet the bag hang at room temperature for several days
BGive other IV drugs through the same lumen to save time
CDisconnect and reconnect the line without cleaning the hub
DUse a dedicated lumen and strict aseptic technique
18.Med-surg: GI, perioperative & oncologyHard
A 74-year-old with chronic kidney disease has severe pain after surgery. Which opioid issue is most important?
AKidney function has no effect on how opioids are handled
BMorphine is the safest opioid in renal failure, so doses can be increased freely
CMorphine metabolites accumulate, so a lower dose or another opioid may be needed
DOpioids must never be used in older adults, whatever the pain
19.Maternity & obstetric nursingMedium
Where is the fundus normally found about 12 hours after a vaginal birth?
AFirm, in the midline, at about the level of the umbilicus
BBelow the symphysis pubis and not palpable
CSoft and two finger-widths above the xiphoid process
DFirm and displaced to the far left side
20.Maternity & obstetric nursingHard
Why does the foramen ovale close soon after birth?
ABlood flow to the lungs decreases after birth
BThe umbilical vein carries more blood to the heart
CProstaglandin levels rise in the newborn's blood
DLeft atrial pressure rises above right atrial pressure
21.Pediatric nursingMedium
A 3-day-old has a red, swollen eyelid with a heavy discharge of pus. What should the nurse do?
AArrange prompt medical review, as infection from the birth canal is possible
BReassure the parents that sticky eyes are always harmless in the first weeks of life
CApply an over-the-counter steroid eye ointment
DClean the eye with breast milk and review in a week
22.Pediatric nursingHard
A child on a morphine infusion is very hard to wake, with a respiratory rate of 8 per minute and pinpoint pupils. What should the nurse do first?
AStop the infusion, support breathing and give naloxone as per protocol
BLet the child sleep, as this shows the pain is controlled
CGive a sedative to keep the child calm
DReduce the infusion rate slightly and recheck the child's breathing in an hour
23.Mental health nursingMedium
Which signs are typical of opioid withdrawal?
APinpoint pupils and slow breathing
BHigh fever, lead-pipe rigidity and confusion within a day of the last dose
CDeep sleep and constipation
DYawning, a runny nose, dilated pupils, goosebumps and diarrhoea
24.Mental health nursingHard
A patient who takes fluoxetine in the evening says he has had trouble falling asleep since starting it. What should the nurse suggest?
ADiscuss with the prescriber whether he can take it in the morning instead
BStop the fluoxetine at once and tell the prescriber at his next appointment
CDrink a small glass of wine or beer before bed to help him fall asleep
DTake a double dose at night to make him sleepy
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 5 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.
5 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 ¼ cup of tea, 1 tsp of cough syrup, 4 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 fl oz = 30 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 60 kg and is prescribed 15 mg/kg as a single dose. Find the dose D in mg.
60 kg15 mg/kg
D = mg
28.Dosage calculationsHard
The prescription is 800 units of a drug that comes as 5000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
800 units5000 units/mL
V = mL
29.IV infusion ratesMedium
A drip runs at 75 gtt/min through a set of 60 gtt/mL. How many millilitres V does the patient receive in 8 hours?
75 gtt/min60 gtt/mL8 h
V = mL
30.IV infusion ratesHard
A bag contains 400 mg of a drug in 100 mL and runs at 20 mL/h. How many milligrams per hour D does the patient receive?
400 mg/100 mL20 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 250 mL. The order is 6 units/h. Find the pump rate R in mL/h. Round to one decimal place.
100 units/250 mL6 units/h
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 800 mg in 500 mL. The order is 10 mcg/kg/min for a patient who weighs 106 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL10 mcg/kg/min106 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 12-hour shift. The patient weighs 91 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 14:30 at 100 mL/h. After 4 hours the rate is changed to 125 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 mL100 mL/h · 4 h125 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 12/min, SpO₂ 99% on supplemental oxygen, blood pressure 118/70 mmHg, pulse 44/min, alert, temperature 37.4 °C. What is the NEWS2 total score?
RR 12SpO₂ 99%O₂SBP 118HR 44AT 37.4 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 70 mmHg. A patient’s systolic pressure is 106 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 70 mmHg?
MAP 70 mmHgSBP 106 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.52, PaCO₂ 48 mmHg (6.4 kPa) and HCO₃⁻ 38 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.52PaCO₂ 48 mmHg (6.4 kPa)HCO₃⁻ 38 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 36 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 36 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
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
1accelerated junctional rhythm
2ventricular tachycardia
3atrial flutter, 2:1 conduction
4supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1atrial fibrillation
2third-degree (complete) AV block
3second-degree AV block type I (Wenckebach)
4first-degree AV block
3Solutions
1.Nursing fundamentals
Answer: B · Increasing redness, warmth, swelling, pain and pus
Why this is the answer
Spreading redness, heat, swelling, pain, pus or an unpleasant smell suggest infection, sometimes with fever. Pink granulation tissue and itching are signs of normal healing.
Answer
B · Increasing redness, warmth, swelling, pain and pus
2.Nursing fundamentals
Answer: D · Inform the prescriber so the omission can be reviewed
Why this is the answer
Unexplained differences between home and hospital medicines are reported to the prescriber. Missed anticoagulants can cause clots, and some omissions are deliberate, for example before surgery.
Answer
D · Inform the prescriber so the omission can be reviewed
3.Infection control & patient safety
Answer: D · Use latex-free supplies and schedule the patient as the first case of the day
Why this is the answer
Latex proteins can become airborne on glove powder and settle in the room. Using a latex-safe room and supplies and scheduling the patient first, when airborne latex is lowest, reduce the risk.
Answer
D · Use latex-free supplies and schedule the patient as the first case of the day
4.Infection control & patient safety
Answer: A · “We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
Why this is the answer
Soft bedding, bumpers and loose blankets increase the risk of suffocation and sudden infant death. The crib should hold only a firm mattress with a fitted sheet.
Answer
A · “We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
5.Prioritization & delegation
Answer: B · “I will use my reliever inhaler and get emergency help straight away.”
Why this is the answer
A red-zone reading means a severe flare. The patient uses their quick-relief inhaler as in their action plan and seeks emergency care at once.
Answer
B · “I will use my reliever inhaler and get emergency help straight away.”
6.Prioritization & delegation
Answer: B · Seizure precautions and close neurological checks
Why this is the answer
Severe hyponatremia can cause seizures and falls. The nurse keeps the patient safe and reports changes; free water is restricted rather than encouraged, as prescribed.
Answer
B · Seizure precautions and close neurological checks
7.Clinical nursing
Answer: A · Diverticulitis
Why this is the answer
Diverticulitis is inflammation of diverticula, usually in the sigmoid colon, so pain is typically in the left iliac fossa. It is common in older adults.
Answer
A · Diverticulitis
8.Clinical nursing
Answer: C · Jaw thrust
Why this is the answer
A jaw thrust opens the airway with minimal neck movement. The cervical spine is protected with manual in-line stabilisation, although opening the airway still takes priority if it remains obstructed.
Answer
C · Jaw thrust
9.Lab values & electrolytes
Answer: B · Higher, about 2.5–3.5
Why this is the answer
Mechanical heart valves, especially in the mitral position, have a high risk of thrombosis, so the INR target is usually higher, about 2.5–3.5. An INR of 5 or more carries a high bleeding risk.Checked against:Label: WARFARIN SODIUM tablet · DailyMed (NLM/FDA) (2012)
In sepsis, falling platelets (coagulation), a rising creatinine (kidney) and a raised bilirubin (liver) show organ dysfunction, which indicates severe disease. The other sets are normal or near normal.Checked against:Bacterial Sepsis · StatPearls (NCBI Bookshelf) (2023); Laboratory Evaluation of Sepsis · StatPearls (NCBI Bookshelf) (2023)
Answer
D · Platelets 70 × 10³/µL, creatinine doubled, bilirubin raised
11.Pharmacology
Answer: A · Take it on an empty stomach, 30–60 minutes before breakfast
Why this is the answer
Levothyroxine is best absorbed on an empty stomach, and calcium, iron and antacids should be taken some hours apart. It is taken every day, usually for life.
Answer
A · Take it on an empty stomach, 30–60 minutes before breakfast
12.Pharmacology
Answer: C · It is nephrotoxic and ototoxic with a narrow therapeutic index
Why this is the answer
Aminoglycosides like gentamicin can damage the kidneys and the inner ear. They are cleared renally, so levels rise in kidney impairment and are monitored.
Answer
C · It is nephrotoxic and ototoxic with a narrow therapeutic index
13.Med-surg: cardiovascular & respiratory
Answer: A · Stretch and pressure overload of the ventricles
Why this is the answer
Natriuretic peptides are released by ventricular myocytes in response to wall stretch. A normal level makes heart failure unlikely; a raised level supports the diagnosis and reflects severity. Levels can also be raised in renal failure and older age. Troponin, not BNP, reflects myocardial necrosis.
Answer
A · Stretch and pressure overload of the ventricles
14.Med-surg: cardiovascular & respiratory
Answer: D · Switch to nasal cannula at low flow, keeping SpO₂ at 88–92%
Why this is the answer
Oxygen is prescribed to a target range and should not be stopped for meals in a patient who needs it. Nasal cannulae allow eating and talking; the flow (for example 1–2 L/min) is titrated to keep the saturation in the target range. High-concentration oxygen risks hypercapnia.
Answer
D · Switch to nasal cannula at low flow, keeping SpO₂ at 88–92%
15.Med-surg: neuro, endocrine & renal
Answer: B · 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
B · 5, localises to pain
16.Med-surg: neuro, endocrine & renal
Answer: B · A pseudo-relapse caused by infection
Why this is the answer
Infection and fever can temporarily worsen existing MS symptoms without new damage (a pseudo-relapse). The infection, here probably a UTI, is treated first. Steroids for a true relapse are considered only if the infection is excluded.
Answer
B · A pseudo-relapse caused by infection
17.Med-surg: GI, perioperative & oncology
Answer: D · Use a dedicated lumen and strict aseptic technique
Why this is the answer
PN is rich in nutrients that bacteria can use. A dedicated lumen, aseptic non-touch technique and hanging limits reduce catheter-related bloodstream infection.
Answer
D · Use a dedicated lumen and strict aseptic technique
18.Med-surg: GI, perioperative & oncology
Answer: C · Morphine metabolites accumulate, so a lower dose or another opioid may be needed
Why this is the answer
Morphine's active metabolites (such as morphine-6-glucuronide) are renally excreted and accumulate in kidney impairment, causing sedation and respiratory depression. Lower doses, longer intervals or alternative opioids may be used with close monitoring. Older age increases sensitivity.
Answer
C · Morphine metabolites accumulate, so a lower dose or another opioid may be needed
19.Maternity & obstetric nursing
Answer: A · Firm, in the midline, at about the level of the umbilicus
Why this is the answer
The fundus rises to about the umbilicus within the first 12 hours, then descends about 1 cm (one finger-width) a day. It is usually no longer palpable above the symphysis by about 2 weeks.
Answer
A · Firm, in the midline, at about the level of the umbilicus
20.Maternity & obstetric nursing
Answer: D · Left atrial pressure rises above right atrial pressure
Why this is the answer
With the first breaths, pulmonary resistance falls and more blood returns to the left atrium, while cord clamping lowers right-sided pressure. The higher left atrial pressure pushes the flap of the foramen ovale shut.
Answer
D · Left atrial pressure rises above right atrial pressure
21.Pediatric nursing
Answer: A · Arrange prompt medical review, as infection from the birth canal is possible
Why this is the answer
Neonatal conjunctivitis with heavy pus and swelling may be caused by gonococcus or chlamydia acquired during birth. Gonococcal infection can damage the cornea rapidly, so swabs and prompt treatment are needed, and the parents are tested and treated too.
Answer
A · Arrange prompt medical review, as infection from the birth canal is possible
22.Pediatric nursing
Answer: A · Stop the infusion, support breathing and give naloxone as per protocol
Why this is the answer
Deep sedation, slow breathing and pinpoint pupils indicate opioid toxicity. The opioid is stopped, the airway and breathing supported with oxygen or bag-mask ventilation if needed, naloxone given as prescribed and help called.
Answer
A · Stop the infusion, support breathing and give naloxone as per protocol
23.Mental health nursing
Answer: D · Yawning, a runny nose, dilated pupils, goosebumps and diarrhoea
Why this is the answer
Opioid withdrawal causes rhinorrhoea, lacrimation, yawning, mydriasis, piloerection, abdominal cramps, diarrhoea and anxiety. It is very unpleasant but rarely life-threatening in healthy adults.
Answer
D · Yawning, a runny nose, dilated pupils, goosebumps and diarrhoea
24.Mental health nursing
Answer: A · Discuss with the prescriber whether he can take it in the morning instead
Why this is the answer
Fluoxetine can be activating and cause insomnia. Taking it in the morning, with the prescriber's agreement, often helps. Stopping suddenly or using alcohol is unsafe.
Answer
A · Discuss with the prescriber whether he can take it in the morning instead
25.Nursing math & unit conversions
Answer: h = 160 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
5·12 + 3 = 63 in
Inches to centimetres
h = 63·2.54 = 160 cm
Answer
h = 160 cm
26.Nursing math & unit conversions
Answer: V = 185 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
¼ cup = 0.25·240 = 60 mL
1 tsp = 1·5 = 5 mL
4 fl oz = 4·30 = 120 mL
Add
V = 60 + 5 + 120 = 185 mL
Answer
V = 185 mL
27.Dosage calculations
Answer: D = 900 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
15·60 = 900 mg
Answer
D = 900 mg
28.Dosage calculations
Answer: V = 0.16 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 800/5000 = 0.16 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.16 mL
29.IV infusion rates
Answer: V = 600 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
75·60/60 = 75 mL/h
Volume
V = 75·8 = 600 mL
Answer
V = 600 mL
30.IV infusion rates
Answer: D = 80 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
400/100 = 4 mg/mL
Dose rate
D = 4·20 = 80 mg/h
Answer
D = 80 mg/h
31.Pediatric & critical-care dosing
Answer: R = 15 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.
Concentration
100/250 = 0.4 units/mL
Pump rate
R = 6/0.4 = 15 mL/h
Answer
R = 15 mL/h
32.Pediatric & critical-care dosing
Answer: R = 39.8 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
10·106 = 1060 mcg/min
1060·60 = 63600 mcg/h
Pump rate
R = 63600/1600 = 39.75 ≈ 39.8 mL/h
Answer
R = 39.8 mL/h
33.IV fluids & fluid balance
Answer: U = 1.42 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
300 + 325 + 475 + 450 = 1550 mL
Per kilogram per hour
U = 1550/(91·12) = 1.419 ≈ 1.42 mL/kg/h
Answer
U = 1.42 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 4.8 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
100·4 = 400 mL
500 − 400 = 100 mL left
Second part
100/125 = 0.8 h
Total time
t = 4 + 0.8 = 4.8 h
Answer
t = 4.8 h
That is about 4 h 48 min, so the bag runs out at about 19:18.
35.Clinical assessment scores
Answer: NEWS2 = 3
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 12/min → 0
SpO₂ 99% → 0
on oxygen → 2
SBP 118 mmHg → 0
HR 44/min → 1
alert (A) → 0
T 37.4 °C → 0
Add
NEWS2 = 0 + 0 + 2 + 0 + 1 + 0 + 0 = 3
Answer
NEWS2 = 3
36.Clinical assessment scores
Answer: DBP = 52 mmHg
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Rearrange
DBP = (3·MAP − SBP)/2
Substitute
DBP = (3·70 − 106)/2 = 104/2 = 52 mmHg
Answer
DBP = 52 mmHg
37.Arterial blood gas interpretation
Answer: partially compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.52: alkalaemia (above 7.45)
PaCO₂ 48 mmHg: high (35–45)
HCO₃⁻ 38 mmol/L: high (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 46.2 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
0.7·36 + 21 = 46.2 mmHg
Answer
PaCO₂ = 46.2 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: supraventricular tachycardia (SVT)
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC. Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Five steps
1. Rate: R–R = 10 small boxes, 1500 ÷ 10 ≈ 150 per minute.
2. Rhythm: regular, every R–R is 0.40 s.
3. P waves: none visible; at this rate they are hidden in the QRS complexes or the T waves.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s), so the rhythm starts above the ventricles.
Interpretation
supraventricular tachycardia (SVT)
Answer
supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretation
Answer: second-degree AV block type I (Wenckebach)
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Five steps
1. Rate: 4 QRS complexes in 6 s, × 10 = 40 per minute.
2. Rhythm: regularly irregular, the QRS complexes come in groups separated by a pause (group beating).
3. P waves: upright and regular (P–P 1.00 s, 60 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: lengthens 0.20 → 0.34 s, then a P wave is not conducted.
5. QRS: 0.10 s, narrow (below 0.12 s).
Interpretation
second-degree AV block type I (Wenckebach)
Answer
second-degree AV block type I (Wenckebach)
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