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
Before discharge, what is most important to confirm about the patient's new medicines?
AThat they know which company makes each drug
BThat they know how and when to take them and what to report
CThat they know the chemical name of each drug
DThat they know the price of each medicine and where to buy it
2.Nursing fundamentalsHard
A patient spills hot tea on their forearm. What is the best immediate first aid?
ACover it with butter or a greasy cream
BCool the burn under cool running water for about 20 minutes
CPut ice or an ice pack directly on the burn for about 10 minutes
DPop any blisters to let the heat escape
3.Infection control & patient safetyMedium
Which toy is safest for a toddler?
AA large toy with no small parts that can come off
BA balloon to play with when an adult is out of the room
CA bag of marbles to sort by color
DA toy with small magnets that come out easily
4.Infection control & patient safetyHard
Which action by a nurse shows that the five moments of hand hygiene are being followed?
AShe wears the same gloves between two patients
BShe cleans her hands only at the start and end of the shift
CShe cleans her hands after touching the bed rail
DShe cleans her hands only when they look dirty
5.Prioritization & delegationMedium
Which finding is unexpected and needs prompt follow-up?
AA patient with known cirrhosis has yellow skin that has not changed
BA patient with long-standing COPD has a barrel-shaped chest
CA patient one day after laparoscopic gallbladder surgery has right shoulder pain
DA patient on a heparin infusion has a new black, tarry stool
6.Prioritization & delegationHard
A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?
A“I will check with the pharmacist before cold remedies.”
B“A sudden severe headache is a warning sign.”
C“I will avoid tap beer and red wine.”
D“I can still eat aged cheese and cured salami.”
7.Clinical nursingMedium
A patient with pneumonia is breathless and coughing up thick sputum. Which nursing measure helps most with breathing?
ALying the patient flat so that they can rest and conserve energy
BDiscouraging coughing to save energy
CRestricting all oral fluids
DSitting the patient upright and supporting them to clear secretions
8.Clinical nursingHard
A patient on metformin with reduced kidney function is due a CT scan with IV contrast. Why might metformin be withheld?
AMetformin makes the images blurry
BMetformin causes severe bleeding during scans
CMetformin reacts with the contrast to cause severe hyperglycaemia
DThere is a risk of lactic acidosis if kidney function worsens
9.Lab values & electrolytesMedium
When do the blood counts usually reach their lowest point (nadir) after many standard chemotherapy regimens?
AOn the same day as treatment
BAbout 7–14 days after treatment
CWithin 1–2 hours of treatment
DAbout 6 months after treatment
10.Lab values & electrolytesHard
An older adult with type 2 diabetes is drowsy and very dehydrated. Glucose 920 mg/dL (51 mmol/L), serum osmolality 350 mOsm/kg, pH 7.36, urine ketones negative or trace. Which condition fits best?
ADiabetic ketoacidosis (DKA)
BSyndrome of inappropriate ADH (SIADH)
CMetformin-related lactic acidosis
DHyperosmolar hyperglycemic state (HHS)
11.PharmacologyMedium
Apixaban and rivaroxaban are anticoagulants that directly inhibit:
AFactor Xa
BThrombin
CVitamin K epoxide reductase
DThe platelet P2Y12 receptor
12.PharmacologyHard
Why are antipsychotics used with great caution in older people with dementia?
AThey are not absorbed in people over 65
BThey are linked to a higher risk of stroke and death
CThey always cure the dementia and stop all behaviour problems
DThey cause severe hypoglycaemia in older people
13.Med-surg: cardiovascular & respiratoryMedium
A patient with diabetes is starting a beta-blocker. What should the nurse teach about hypoglycaemia?
AThe beta-blocker will prevent all episodes of hypoglycaemia
BSome warning signs, such as a fast heartbeat, may be masked
CInsulin should be stopped while taking a beta-blocker
DHypoglycaemia will always cause a very slow and weak pulse
14.Med-surg: cardiovascular & respiratoryHard
A patient has new chest pain at rest. The ECG shows ST depression, but serial troponins remain normal. Which diagnosis fits best?
AStable angina
BNon-ST-elevation myocardial infarction
CUnstable angina
DST-elevation myocardial infarction
15.Med-surg: neuro, endocrine & renalMedium
Which action is part of an effective bowel programme after a spinal cord injury?
AUsing strong laxatives only when the bowel has not opened for a week
BAvoiding fibre to prevent bloating
CRestricting fluids to reduce the volume of stool
DA routine at the same time each day, often after a meal
16.Med-surg: neuro, endocrine & renalHard
A patient with polycystic kidney disease suddenly has the worst headache of their life and neck stiffness. What should the nurse suspect?
AA urinary infection that has spread
BA migraine linked to high blood pressure
CA subarachnoid haemorrhage from a brain aneurysm
DPain spreading upwards from a kidney cyst
17.Med-surg: GI, perioperative & oncologyMedium
Which technique is correct when giving a prefilled low molecular weight heparin injection?
AInject into a vein in the back of the hand
BExpel the air bubble first and inject into the deltoid muscle
CLeave the air bubble in and inject into a skin fold
DRub the site firmly afterwards to help absorption
18.Med-surg: GI, perioperative & oncologyHard
A bag of parenteral nutrition runs out and the next one will not arrive for several hours. Which risk should the nurse anticipate?
AAcute urinary retention
BRaised intracranial pressure
CSevere hyperkalaemia
DRebound hypoglycaemia
19.Maternity & obstetric nursingMedium
Which breastfeeding mother should be advised not to breastfeed?
AA mother who had a caesarean birth
BA mother receiving chemotherapy
CA mother with mastitis
DA mother with a common cold
20.Maternity & obstetric nursingHard
A breastfeeding mother asks whether she can have a progestin-only implant before discharge. Which reply is best?
AProgestin-only methods are compatible with breastfeeding
BAny hormonal contraception will stop her milk supply
CImplants contain oestrogen, which is safe in breastfeeding
DShe should wait until she stops breastfeeding before using any method
21.Pediatric nursingMedium
Which finding is an early sign of shock in a child?
AA warm, flushed child with a strong, bounding pulse
BLow blood pressure with a slow heart rate and pauses in breathing
CA fast heart rate with a prolonged capillary refill
DSlow, deep breathing with a normal heart rate
22.Pediatric nursingHard
An infant with a large VSD now breathes faster, sweats during feeds and has gained 300 g overnight with puffy eyelids. What does this most likely indicate?
AGood growth thanks to improved feeding
BAn allergic reaction to the new high-energy formula started yesterday
CDehydration due to sweating during feeds
DWorsening heart failure with fluid retention
23.Mental health nursingMedium
An 84-year-old asks for an over-the-counter sleep aid containing diphenhydramine. What is the main concern?
AIts anticholinergic effects can cause confusion, urine retention and falls
BIt raises blood pressure to dangerous levels in older adults
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 with dementia repeatedly walks towards the ward exit, saying he must go to work. What is the most appropriate action?
AWalk with him, acknowledge his concern and gently redirect him to an activity
BLock him in his room so that he cannot leave
CTell him firmly that he has been retired for 20 years
DUse a physical restraint in a chair for the rest of the day so that he stays safe and cannot reach the exit
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.46269 mL. The rule in this exercise is that volumes below 1 mL are rounded to the nearest hundredth of a mL. What value x do you record?
0.46269 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An order reads 5 mcg/kg/min for a patient who weighs 95 kg. Express the dose rate D in mg/h. Round to two decimal places.
5 mcg/kg/min95 kg
D = mg/h
27.Dosage calculationsMedium
How many milligrams of drug m are in 5 mL of a 5% (w/v) solution?
5% w/v5 mL
m = mg
28.Dosage calculationsHard
A patient weighs 171.6 lb. The prescription is 2 mg/kg as a single dose, and the stock contains 40 mg in 1 mL. Using 1 kg = 2.2 lb, what volume V do you give?
171.6 lb2 mg/kg40 mg/1 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 25 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
25 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 2 g of a drug in 500 mL. The order is 1.5 mg per minute. At what rate R do you set the pump, in mL/h?
2 g/500 mL1.5 mg/min
R = mL/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion contains 100 units of regular insulin in 100 mL. The order is 8 units/h. Find the pump rate R in mL/h. Round to one decimal place.
100 units/100 mL8 units/h
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 250 mg in 250 mL runs at 32 mL/h. The patient weighs 62 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL32 mL/h62 kg
D = mcg/kg/min
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 total intake I in mL.
soup: 250 mLwater: 120 mLIV infusion: 50 mL/h × 8 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 60 mL/h. At 18:30, 200 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL200 mL infused60 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient after a head injury opens the eyes only to pressure (a painful stimulus), makes no sounds and shows as the best motor response: extension of the arms and legs (abnormal extension). Work out the GCS and classify the head injury by it. Click your answer.
1mild
2moderate
3severe
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). The team aims for a mean arterial pressure of at least 60 mmHg. A patient’s systolic pressure is 96 mmHg. Using MAP = (SBP + 2·DBP)/3, what is the lowest diastolic pressure DBP that still gives a MAP of 60 mmHg?
MAP 60 mmHgSBP 96 mmHg
DBP = mmHg
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.30, PaCO₂ 51 mmHg (6.8 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory acidosis. How far is it compensated? Click your answer.
pH 7.30PaCO₂ 51 mmHg (6.8 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
Practice values: Na⁺ 143, Cl⁻ 112, HCO₃⁻ 19 mmol/L and albumin 30 g/L. Find the albumin-corrected anion gap AGc = AG + 0.25·(40 − albumin).
Measure the QT interval and the R–R interval on this regular lead II strip, then calculate the rate-corrected QTc with Bazett’s formula QTc = QT/√RR (both in seconds). Give the answer in seconds to three decimals.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QTc = s
40.ECG rhythm strip interpretationHard
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: B · That they know how and when to take them and what to report
Why this is the answer
Safe discharge needs the patient or carer to understand dose, timing, purpose and important side effects. Teach-back and written information help confirm this.
Answer
B · That they know how and when to take them and what to report
2.Nursing fundamentals
Answer: B · Cool the burn under cool running water for about 20 minutes
Why this is the answer
Cool running water for about 20 minutes reduces pain and depth of injury. Ice can damage tissue further, grease holds heat in, and blisters are left intact to protect the skin.
Answer
B · Cool the burn under cool running water for about 20 minutes
3.Infection control & patient safety
Answer: A · A large toy with no small parts that can come off
Why this is the answer
Small parts, marbles, magnets and uninflated or broken balloons are choking hazards for young children. Toys should be large, sturdy and suited to the child’s age.
Answer
A · A large toy with no small parts that can come off
4.Infection control & patient safety
Answer: C · She cleans her hands after touching the bed rail
Why this is the answer
Touching the patient’s surroundings, such as rails and tables, contaminates the hands, so hand hygiene is needed afterwards. Gloves are changed between patients, and hand hygiene is needed whether or not the hands look dirty.
Answer
C · She cleans her hands after touching the bed rail
5.Prioritization & delegation
Answer: D · A patient on a heparin infusion has a new black, tarry stool
Why this is the answer
Black, tarry stool (melena) suggests bleeding from the upper gut, a dangerous complication of anticoagulation. Shoulder pain after laparoscopy from the gas used is common, and a barrel chest in COPD and stable jaundice in cirrhosis are expected.
Answer
D · A patient on a heparin infusion has a new black, tarry stool
6.Prioritization & delegation
Answer: D · “I can still eat aged cheese and cured salami.”
Why this is the answer
MAO inhibitors with tyramine-rich foods, such as aged cheese and cured meats, can cause a hypertensive crisis. Patients avoid these foods, check medicines with a pharmacist and report a severe headache.
Answer
D · “I can still eat aged cheese and cured salami.”
7.Clinical nursing
Answer: D · Sitting the patient upright and supporting them to clear secretions
Why this is the answer
An upright position improves lung expansion, and adequate fluids, deep breathing and coughing help clear sputum. Oxygen is given to target saturations if needed.
Answer
D · Sitting the patient upright and supporting them to clear secretions
8.Clinical nursing
Answer: D · There is a risk of lactic acidosis if kidney function worsens
Why this is the answer
Iodinated contrast can worsen kidney function, and metformin can then accumulate and cause lactic acidosis. Local policy guides when to stop and restart it.
Answer
D · There is a risk of lactic acidosis if kidney function worsens
9.Lab values & electrolytes
Answer: B · About 7–14 days after treatment
Why this is the answer
Chemotherapy damages dividing marrow cells, but mature neutrophils and platelets already in the blood survive for a while, so counts usually fall to a nadir about 7–14 days later, depending on the drug. Infection and bleeding risks are highest then.
Answer
B · About 7–14 days after treatment
10.Lab values & electrolytes
Answer: D · Hyperosmolar hyperglycemic state (HHS)
Why this is the answer
HHS causes extreme hyperglycemia and high osmolality with severe dehydration, but enough insulin is present to prevent significant ketosis, so the pH is near normal. DKA has ketones and acidosis; SIADH has low osmolality.Checked against:Ketoacidosis · StatPearls (NCBI Bookshelf) (2023); Osmolality blood test · MedlinePlus (NIH) (2025)
Answer
D · Hyperosmolar hyperglycemic state (HHS)
11.Pharmacology
Answer: A · Factor Xa
Why this is the answer
Apixaban and rivaroxaban are direct factor Xa inhibitors. Dabigatran directly inhibits thrombin, warfarin blocks vitamin K recycling and clopidogrel blocks P2Y12.
Answer
A · Factor Xa
12.Pharmacology
Answer: B · They are linked to a higher risk of stroke and death
Why this is the answer
In older people with dementia, antipsychotics increase the risk of stroke and death. Non-drug approaches are tried first, and antipsychotics are used at low doses for short periods if needed.
Answer
B · They are linked to a higher risk of stroke and death
13.Med-surg: cardiovascular & respiratory
Answer: B · Some warning signs, such as a fast heartbeat, may be masked
Why this is the answer
Beta-blockers can blunt adrenergic symptoms of hypoglycaemia such as palpitations and tremor. Sweating usually remains. Patients should check their glucose if they feel unwell and know their other warning signs.
Answer
B · Some warning signs, such as a fast heartbeat, may be masked
14.Med-surg: cardiovascular & respiratory
Answer: C · Unstable angina
Why this is the answer
Unstable angina is new, worsening or rest angina without a troponin rise. It is an acute coronary syndrome and is managed urgently because it can progress to infarction. Stable angina is predictable and exertional. NSTEMI has a rising troponin.
Answer
C · Unstable angina
15.Med-surg: neuro, endocrine & renal
Answer: D · A routine at the same time each day, often after a meal
Why this is the answer
A regular routine, timed after a meal to use the gastrocolic reflex, plus fluids, fibre and, often, suppositories or digital stimulation, helps prevent constipation and accidents. This also reduces the risk of autonomic dysreflexia.
Answer
D · A routine at the same time each day, often after a meal
16.Med-surg: neuro, endocrine & renal
Answer: C · A subarachnoid haemorrhage from a brain aneurysm
Why this is the answer
Adult polycystic kidney disease is associated with berry aneurysms. A sudden thunderclap headache suggests subarachnoid haemorrhage and needs emergency assessment and CT imaging.
Answer
C · A subarachnoid haemorrhage from a brain aneurysm
17.Med-surg: GI, perioperative & oncology
Answer: C · Leave the air bubble in and inject into a skin fold
Why this is the answer
LMWH is injected into a pinched skin fold, often on the abdomen, away from the umbilicus. The air bubble in prefilled syringes is left in, and the site is not rubbed, to reduce bruising.
Answer
C · Leave the air bubble in and inject into a skin fold
18.Med-surg: GI, perioperative & oncology
Answer: D · Rebound hypoglycaemia
Why this is the answer
Stopping PN suddenly can cause hypoglycaemia because insulin levels stay high for a while. Glucose is monitored, and a glucose infusion may be given according to local policy.
Answer
D · Rebound hypoglycaemia
19.Maternity & obstetric nursing
Answer: B · A mother receiving chemotherapy
Why this is the answer
Breastfeeding is contraindicated with most cytotoxic chemotherapy, untreated active tuberculosis, use of illicit drugs, and in an infant with galactosaemia. Mastitis and colds are not reasons to stop.
Answer
B · A mother receiving chemotherapy
20.Maternity & obstetric nursing
Answer: A · Progestin-only methods are compatible with breastfeeding
Why this is the answer
Progestin-only methods such as implants, injections and pills do not have a clinically important effect on milk supply. Oestrogen-containing methods are usually avoided in the first weeks.
Answer
A · Progestin-only methods are compatible with breastfeeding
21.Pediatric nursing
Answer: C · A fast heart rate with a prolonged capillary refill
Why this is the answer
Children maintain their blood pressure until late in shock. Early signs include tachycardia, prolonged capillary refill, cool peripheries, reduced urine output and changes in behaviour.
Answer
C · A fast heart rate with a prolonged capillary refill
22.Pediatric nursing
Answer: D · Worsening heart failure with fluid retention
Why this is the answer
A sudden overnight weight gain with periorbital oedema, tachypnoea and sweating suggests fluid retention from worsening heart failure. Daily weights on the same scale are a key way to monitor fluid status in these infants.
Answer
D · Worsening heart failure with fluid retention
23.Mental health nursing
Answer: A · 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
A · Its anticholinergic effects can cause confusion, urine retention and falls
24.Mental health nursing
Answer: A · Walk with him, acknowledge his concern and gently redirect him to an activity
Why this is the answer
Wandering often has a reason, such as a past routine, boredom or a physical need. Redirection, meaningful activity and a safe environment are preferred over restraint, which increases agitation and the risk of injury.
Answer
A · Walk with him, acknowledge his concern and gently redirect him to an activity
25.Nursing math & unit conversions
Answer: x = 0.46 mL
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 hundredths place
0.46269 → 6
Only the next digit decides
0.46269 → 2
2 is 4 or less, so 6 stays.
The digits after it (69) are ignored: round once, never step by step.
Round
x = 0.46 mL
Answer
x = 0.46 mL
26.Nursing math & unit conversions
Answer: D = 28.5 mg/h
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.
Set up the chain
D = 5 mcg/kg/min × 95 kg × (60 min/1 h) × (1 mg/1000 mcg)
Calculate
D = 5·95·60/1000 = 28.5 mg/h
Answer
D = 28.5 mg/h
27.Dosage calculations
Answer: m = 250 mg
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Concentration
5% = 5 g/100 mL = 50 mg/mL
Mass of drug
m = 50·5 = 250 mg
Answer
m = 250 mg
28.Dosage calculations
Answer: V = 3.9 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
171.6/2.2 = 78 kg
Dose
2·78 = 156 mg
Volume
V = (156/40)·1 = 3.9 mL
Answer
V = 3.9 mL
29.IV infusion rates
Answer: R = 25 gtt/min
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.
Millilitres per minute
25/60 = 0.4167 mL/min
Drip rate
R = 0.4167·60 = 25 gtt/min
Answer
R = 25 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: R = 22.5 mL/h
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
2000 mg/500 mL = 4 mg/mL
Dose per hour
1.5·60 = 90 mg/h
Pump rate
R = 90/4 = 22.5 mL/h
Answer
R = 22.5 mL/h
31.Pediatric & critical-care dosing
Answer: R = 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.
Concentration
100/100 = 1 units/mL
Pump rate
R = 8/1 = 8 mL/h
Answer
R = 8 mL/h
32.Pediatric & critical-care dosing
Answer: D = 8.6 mcg/kg/min
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
250 000/250 = 1000 mcg/mL
Micrograms per minute
32·1000 = 32000 mcg/h
32000/60 = 533.3 mcg/min
Per kilogram
D = 533.3/62 = 8.602 ≈ 8.6 mcg/kg/min
Answer
D = 8.6 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 870 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.
Add the intake
oral: 250 + 120 = 370 mL
IV infusion: 50·8 = 400 mL
IV antibiotic: 1·100 = 100 mL
I = 870 mL
Answer
I = 870 mL
34.IV fluids & fluid balance
Answer: t = 5 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 − 200 = 300 mL
Time
t = 300/60 = 5 h
Answer
t = 5 h
That is about 5 h 00 min, so the bag runs out at about 23:30.
35.Clinical assessment scores
Answer: severe
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Score each area
E: opens the eyes only to pressure (a painful stimulus) → 2
V: makes no sounds → 1
M: extension of the arms and legs (abnormal extension) → 2
Add
GCS = 2 + 1 + 2 = 5
Severity
GCS 5 → severe
Answer
severe
36.Clinical assessment scores
Answer: DBP = 42 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 = (3·60 − 96)/2 = 84/2 = 42 mmHg
Answer
DBP = 42 mmHg
37.Arterial blood gas interpretation
Answer: uncompensated
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 7.30: acidaemia (below 7.35)
PaCO₂ 51 mmHg: high (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: AGc = 14.5 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 = 143 − (112 + 19) = 12
Correction for albumin
12 + 0.25·(40 − 30) = 14.5 mmol/L
Answer
AGc = 14.5 mmol/L
Above about 12 after correction: a high anion gap.
39.ECG rhythm strip interpretation
Answer: QTc = 0.412 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
QT = 8.5 × 0.04 = 0.34 s
RR = 17 × 0.04 = 0.68 s
Bazett’s formula
QTc = 0.34/√0.68 = 0.34/0.8246 = 0.412 s
Answer
QTc = 0.412 s
Within the usual limits (about 0.45 s for men, 0.46 s for women). (412 ms)
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 = 0.96 s, regular; one P wave in every 4 is not conducted
PR in each group
PR₁ = 0.20 s, PR₂ = 0.34 s, PR₃ = 0.40 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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