Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
A large pressure ulcer is left open and fills in with new tissue from its base. This is called healing by:
APrimary intention
BSecondary intention
CDelayed intention
DTertiary intention
2.Nursing fundamentalsHard
An older patient's leg wound has become more painful and has a new unpleasant smell, but there is no fever. What does this suggest?
AThe wound has dried out and needs to be left open
BAn allergy to the dressing that needs no action
CA possible wound infection that needs assessment and reporting
DNormal healing, because there is no fever and the wound is still closed
3.Infection control & patient safetyMedium
A patient with a severe latex allergy is booked for surgery. Which measure is commonly used?
AUse latex gloves only for short procedures
BGive the patient antihistamines before surgery and then use the normal supplies
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
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
CGive the dose anyway, because the medication tray was cleaned this morning
DDiscard the syringe and prepare the dose again with new equipment
5.Prioritization & delegationMedium
Which statement shows correct understanding of accountability in delegation?
A“If the task goes wrong, only the assistant is responsible.”
B“Once I delegate a task, it is no longer my concern.”
C“The nursing assistant is accountable for whether the task was right to delegate.”
D“I stay accountable for deciding to delegate and for following up on the result.”
6.Prioritization & delegationHard
In a disaster with very limited resources, a victim with severe burns over almost the whole body is tagged black. Which principle explains this decision?
ADoing the greatest good for the greatest number
BTreating the youngest victims first
CTreating the most severely injured person first
DTreating victims in the order in which they arrive
7.Clinical nursingMedium
Which measure helps prevent delirium in older inpatients?
AMoving the patient to a different bed each night to give them a change of scene
BRestricting fluids to avoid incontinence
CReorientation, glasses and hearing aids in use, and good sleep and hydration
DKeeping the lights on all night
8.Clinical nursingHard
A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?
ALoss of circulation to the hand as swelling builds under tight burned skin
BExcessive bleeding from the burn surface needing an urgent blood transfusion
CDelayed hair growth on the arm
DHypoglycaemia caused by the body using glucose to heal the burn
9.Lab values & electrolytesMedium
How often is the INR usually checked when warfarin is first started?
AEvery few days, until it is stable
BOnce a year, at a routine visit
CEvery hour, during the first week
DOnly if bleeding occurs at home
10.Lab values & electrolytesHard
A patient's low calcium does not improve despite several days of calcium replacement. Which other electrolyte should be checked and corrected?
ABicarbonate
BChloride
CMagnesium
DSodium
11.PharmacologyMedium
When should a patient take a once-daily proton pump inhibitor such as omeprazole?
AStraight after a large evening meal
BAbout 30–60 minutes before the first meal of the day
COnly when heartburn is severe
DWith a glass of milk at bedtime, when acid output is highest
12.PharmacologyHard
Five days after starting clindamycin, a patient has frequent watery diarrhoea, abdominal cramps and a fever. What should the nurse suspect and do?
AAn allergy to clindamycin; give an antihistamine and continue the antibiotic
BA normal side effect; give loperamide and continue as usual
CFood poisoning; encourage a high-fibre diet and plenty of milk products
DC. difficile infection; send stool, use contact precautions, avoid antidiarrhoeals
13.Med-surg: cardiovascular & respiratoryMedium
A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?
AA theophylline allergy causing a rash
BHypoglycaemia caused by the drug
CTheophylline toxicity
DAn expected sign that the drug is working
14.Med-surg: cardiovascular & respiratoryHard
A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?
AIt improves oxygenation; risks are pressure injury and tube displacement
BIt lowers the blood pressure; the main risk is rebound hypertension
CIt treats infection; the risk is fever
DIt improves digestion and gut motility; the main risk is constipation
15.Med-surg: neuro, endocrine & renalMedium
Why are insulin and glucose given together to treat hyperkalaemia?
AInsulin protects the heart muscle cells from the potassium
BInsulin moves potassium into cells; glucose prevents a hypo
CGlucose binds the potassium in the blood and removes it
DInsulin makes the kidneys pass more potassium in the urine
16.Med-surg: neuro, endocrine & renalHard
A patient had a left-arm AV fistula created yesterday and needs routine bloods. Which instruction is most important?
AWrap the left arm tightly in a bandage to protect the fistula
BUse a tight tourniquet on the left arm to find a good vein
CTake blood from the fistula, as it is easy to find and large
DUse the right arm; check the left hand's circulation and thrill
17.Med-surg: GI, perioperative & oncologyMedium
Which PPE is usually recommended when giving cytotoxic chemotherapy?
ANo PPE, because the infusion bag is sealed
BOrdinary cotton gloves and a plastic apron
CA paper surgical mask but no gloves
DChemo-tested gloves and impermeable gown
18.Med-surg: GI, perioperative & oncologyHard
A patient on a long-term opioid for chronic pain is admitted for surgery. Which statement is correct?
AThe usual opioid is continued, plus extra analgesia, due to tolerance
BThey need lower postoperative opioid doses than opioid-naive patients
CThey should receive only paracetamol after the operation is over
DAll opioids should be stopped on admission to prevent addiction
19.Maternity & obstetric nursingMedium
Which position of the fetal head presents the smallest diameter to the pelvis?
AFull flexion, with the chin on the chest
BPartial extension, with the brow presenting
CA neutral position with no flexion
DFull extension, with the face presenting
20.Maternity & obstetric nursingHard
A multiparous woman arrives with strong contractions and the baby is born within an hour of their onset. What should the nurse monitor closely afterwards?
AThe mother's ability to walk alone
BOnly the newborn's blood glucose
CUterine tone, bleeding and newborn injury
DOnly the mother's temperature
21.Pediatric nursingMedium
Why are codeine and tramadol not recommended for children under 12 years?
ASome children metabolise them very quickly, causing dangerous breathing depression
BThey are too weak to relieve moderate pain, so stronger opioids are always preferred
CThey always cause allergies
DThey can only be given intravenously
22.Pediatric nursingHard
A child who had a tonsillectomy this morning is swallowing frequently and spitting up bright red blood. What should the nurse do first?
ARecord it in the notes and reassess at the next routine observation round
BEncourage the child to gargle
CGive a warm drink to soothe the throat
DAssess the throat and vital signs and notify the surgeon urgently
23.Mental health nursingMedium
A 19-year-old has just started an antidepressant. What should the nurse monitor especially closely in the first weeks?
AChanges in eye colour
BHair loss
CRapid weight gain
DNew or worsening suicidal thoughts or behaviour
24.Mental health nursingHard
A man whose wife died a month ago is rude and angry with the nurses about small things. What is the best understanding of his behaviour?
AHe does not care about his wife's death and is using it as an excuse to be rude
BHe has antisocial personality disorder that was not noticed before
CHe should be told that his behaviour is unacceptable and that visits will be stopped
DHis anger may be part of grief, displaced onto staff, so she should not take it personally
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 11:00 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
11:00
11:00 AM
211:00 PM
311:00 AM
410:00 AM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes ½ fl oz of juice, 3 cups of tea, 2 tbsp of liquid supplement. Using the equivalents given, find the total oral intake V in mL.
1 fl oz = 30 mL1 cup = 8 fl oz = 240 mL1 tbsp = 15 mL
V = mL
27.Dosage calculationsMedium
A patient weighing 79 kg has a body surface area of 1.67 m². The prescription is 75 mg/m². Find the dose D in mg.
79 kgBSA = 1.67 m²75 mg/m²
D = mg
28.Dosage calculationsHard
The prescription is 420 units of a drug that comes as 1000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
420 units1000 units/mL
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 150 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.
150 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
1000 mL was ordered over 12 hours. After 7 hours you find that 520 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1000 mL / 12 hafter 7 h: 520 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 50 units of regular insulin in 50 mL runs at 2 mL/h. How many units per hour D does the patient receive?
50 units/50 mL2 mL/h
D = units/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 71 kg has an order for nitroglycerin at 30 mcg/min. The bag contains 25 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
25 mg/250 mL30 mcg/min71 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 150 mL/h. At 16:00, 550 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL550 mL infused150 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 83/min and a blood pressure of 151/83 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 83/minBP 151/83 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 121 kg and is 165 cm tall. Calculate the BMI and click the WHO weight category.
121 kg165 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.22, PaCO₂ 79 mmHg (10.5 kPa) and HCO₃⁻ 31 mmol/L. The primary disorder is respiratory acidosis. How far is it compensated? Click your answer.
pH 7.22PaCO₂ 79 mmHg (10.5 kPa)HCO₃⁻ 31 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 50% oxygen shows PaO₂ 79 mmHg (10.5 kPa) and PaCO₂ 52 mmHg (6.9 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
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
1second-degree AV block type II
2sinus bradycardia
3sinus rhythm with sinus arrest
4sinus rhythm with PVCs
40.ECG rhythm strip interpretationHard
This patient has a pacemaker. Interpret the lead II strip. Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1third-degree (complete) AV block
2sinus rhythm with wide QRS
3ventricular paced rhythm
4paced rhythm, failure to capture
3Solutions
1.Nursing fundamentals
Answer: B · Secondary intention
Why this is the answer
Wounds with tissue loss that cannot be closed heal by secondary intention, with granulation filling the wound and more scarring. Tertiary (delayed primary) closure is when a wound is left open first and closed later.
Answer
B · Secondary intention
2.Nursing fundamentals
Answer: C · A possible wound infection that needs assessment and reporting
Why this is the answer
Increasing pain, odour, new exudate or delayed healing can signal infection even without fever, especially in older adults. The wound is assessed, the change reported and a swab taken if policy advises.
Answer
C · A possible wound infection that needs assessment and reporting
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: D · 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
D · Discard the syringe and prepare the dose again with new equipment
5.Prioritization & delegation
Answer: D · “I stay accountable for deciding to delegate and for following up on the result.”
Why this is the answer
The delegating nurse is accountable for the decision to delegate and for supervising and evaluating. The delegate is responsible for performing the task correctly within their competence.
Answer
D · “I stay accountable for deciding to delegate and for following up on the result.”
6.Prioritization & delegation
Answer: A · Doing the greatest good for the greatest number
Why this is the answer
In a mass-casualty event, resources are used where they save the most lives. A victim who is unlikely to survive even with full treatment is given comfort care, while staff treat salvageable victims. In everyday triage, the sickest patient is usually seen first.
Answer
A · Doing the greatest good for the greatest number
7.Clinical nursing
Answer: C · Reorientation, glasses and hearing aids in use, and good sleep and hydration
Why this is the answer
Multicomponent prevention, including orientation, sensory aids, hydration, nutrition, mobility, sleep and avoiding unnecessary moves or drugs, reduces delirium.
Answer
C · Reorientation, glasses and hearing aids in use, and good sleep and hydration
8.Clinical nursing
Answer: A · Loss of circulation to the hand as swelling builds under tight burned skin
Why this is the answer
Circumferential full-thickness burns form a tight eschar that acts like a tourniquet as oedema develops. Neurovascular checks are needed, and escharotomy may be required.
Answer
A · Loss of circulation to the hand as swelling builds under tight burned skin
9.Lab values & electrolytes
Answer: A · Every few days, until it is stable
Why this is the answer
When warfarin is started or its dose changes, the INR is checked frequently (often every few days) until it is stable in the target range. After that, the interval can be extended, often up to every 4 weeks or longer if very stable.
Answer
A · Every few days, until it is stable
10.Lab values & electrolytes
Answer: C · Magnesium
Why this is the answer
Low magnesium reduces parathyroid hormone secretion and the body's response to it, so hypocalcemia does not correct until magnesium is replaced. The same applies to refractory hypokalemia.Checked against:Magnesium Blood Test · MedlinePlus (NIH) (2023)
Answer
C · Magnesium
11.Pharmacology
Answer: B · About 30–60 minutes before the first meal of the day
Why this is the answer
Proton pump inhibitors block pumps that are active, so they work best when taken before breakfast. Food then activates the pumps when the drug level is high.
Answer
B · About 30–60 minutes before the first meal of the day
12.Pharmacology
Answer: D · C. difficile infection; send stool, use contact precautions, avoid antidiarrhoeals
Why this is the answer
Broad-spectrum antibiotics, especially clindamycin, allow C. difficile to overgrow and release toxins. Stool is tested, contact precautions with soap-and-water handwashing are used, and antidiarrhoeals are avoided because they keep toxin in the gut.
Answer
D · C. difficile infection; send stool, use contact precautions, avoid antidiarrhoeals
13.Med-surg: cardiovascular & respiratory
Answer: C · Theophylline toxicity
Why this is the answer
Theophylline has a narrow therapeutic window. Toxicity causes nausea, vomiting, tachycardia, arrhythmias, agitation and seizures. Levels are monitored, and many drugs and smoking status change its clearance. The nurse should hold the dose and report.
Answer
C · Theophylline toxicity
14.Med-surg: cardiovascular & respiratory
Answer: A · It improves oxygenation; risks are pressure injury and tube displacement
Why this is the answer
Prone positioning improves ventilation–perfusion matching and oxygenation and improves survival in severe ARDS. Turning needs a trained team. Risks include accidental extubation or line removal and pressure damage to the face, chest and knees, so careful positioning and skin checks are essential.
Answer
A · It improves oxygenation; risks are pressure injury and tube displacement
15.Med-surg: neuro, endocrine & renal
Answer: B · Insulin moves potassium into cells; glucose prevents a hypo
Why this is the answer
Insulin activates the sodium–potassium pump, moving potassium into cells and lowering the serum level within about 15–30 minutes. Glucose is given to prevent hypoglycaemia. The effect is temporary, so potassium must also be removed.
Answer
B · Insulin moves potassium into cells; glucose prevents a hypo
16.Med-surg: neuro, endocrine & renal
Answer: D · Use the right arm; check the left hand's circulation and thrill
Why this is the answer
A new fistula is protected from compression and puncture. Nurses check the thrill and bruit, and the hand for warmth, colour and sensation, because the fistula can "steal" blood from the hand. A fistula usually takes several weeks to mature before it can be used for dialysis.
Answer
D · Use the right arm; check the left hand's circulation and thrill
17.Med-surg: GI, perioperative & oncology
Answer: D · Chemo-tested gloves and impermeable gown
Why this is the answer
Cytotoxic drugs can be absorbed through skin or inhaled. Staff use chemotherapy-tested gloves (often double), impermeable long-sleeved gowns and eye protection where splashing could occur, along with closed-system devices and safe disposal.
Answer
D · Chemo-tested gloves and impermeable gown
18.Med-surg: GI, perioperative & oncology
Answer: A · The usual opioid is continued, plus extra analgesia, due to tolerance
Why this is the answer
Patients on long-term opioids have tolerance and physical dependence. Stopping their usual opioid risks withdrawal and uncontrolled pain. Their baseline dose is continued (or converted to another route) and multimodal analgesia added; they often need more opioid than opioid-naive patients, with careful monitoring.
Answer
A · The usual opioid is continued, plus extra analgesia, due to tolerance
19.Maternity & obstetric nursing
Answer: A · Full flexion, with the chin on the chest
Why this is the answer
When the head is fully flexed, the suboccipitobregmatic diameter of about 9.5 cm presents. Extension, as in brow and face presentations, presents larger diameters and can obstruct labour.
Answer
A · Full flexion, with the chin on the chest
20.Maternity & obstetric nursing
Answer: C · Uterine tone, bleeding and newborn injury
Why this is the answer
Precipitous labour increases the risk of cervical and perineal tears, uterine atony and haemorrhage, and of newborn injuries such as bruising or intracranial bleeding.
Answer
C · Uterine tone, bleeding and newborn injury
21.Pediatric nursing
Answer: A · Some children metabolise them very quickly, causing dangerous breathing depression
Why this is the answer
In ultra-rapid metabolisers, codeine is quickly converted to morphine, which can cause life-threatening respiratory depression. Regulators advise against codeine and tramadol in children under 12, and after tonsil or adenoid surgery in those under 18.
Answer
A · Some children metabolise them very quickly, causing dangerous breathing depression
22.Pediatric nursing
Answer: D · Assess the throat and vital signs and notify the surgeon urgently
Why this is the answer
Frequent swallowing and bright red blood suggest postoperative haemorrhage. Keep the child upright or on their side, assess vital signs and the throat with a light, and inform the surgeon at once.
Answer
D · Assess the throat and vital signs and notify the surgeon urgently
23.Mental health nursing
Answer: D · New or worsening suicidal thoughts or behaviour
Why this is the answer
In children and young adults, antidepressants can increase suicidal thinking early in treatment. Close monitoring is needed, especially in the first weeks and after dose changes.
Answer
D · New or worsening suicidal thoughts or behaviour
24.Mental health nursing
Answer: D · His anger may be part of grief, displaced onto staff, so she should not take it personally
Why this is the answer
Anger is a common part of grief and may be directed at staff who are safer targets. The nurse responds calmly, sets limits if needed and invites him to talk about his loss.
Answer
D · His anger may be part of grief, displaced onto staff, so she should not take it personally
25.Nursing math & unit conversions
Answer: 11:00 AM
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Convert the hour
11 → 11 AM
Answer
11:00 AM
Answer
11:00 AM
26.Nursing math & unit conversions
Answer: V = 765 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 fl oz = 0.5·30 = 15 mL
3 cups = 3·240 = 720 mL
2 tbsp = 2·15 = 30 mL
Add
V = 15 + 720 + 30 = 765 mL
Answer
V = 765 mL
27.Dosage calculations
Answer: D = 125.3 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
Dose
D = 75·1.67 = 125.3 mg
Answer
D = 125.3 mg
28.Dosage calculations
Answer: V = 0.42 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 = 420/1000 = 0.42 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.42 mL
29.IV infusion rates
Answer: R = 150 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
150/60 = 2.5 mL/min
Drip rate
R = 2.5·60 = 150 gtt/min
Answer
R = 150 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: Δ = 24.8 %
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
1000/12 = 83.33 mL/h
New rate
R = 520/5 = 104 mL/h
Percentage change
Δ = (104 − 83.33)/83.33·100% = 24.8%
Answer
Δ = 24.8%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: D = 2 units/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
50/50 = 1 units/mL
Units per hour
D = 2·1 = 2 units/h
Answer
D = 2 units/h
32.Pediatric & critical-care dosing
Answer: R = 18 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
25 000/250 = 100 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
30·60 = 1800 mcg/h
Pump rate
R = 1800/100 = 18 mL/h
Answer
R = 18 mL/h
33.IV fluids & fluid balance
Answer: B = −360 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total intake
oral: 200 + 100 = 300 mL
IV infusion: 125·8 = 1000 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1500 mL
Total output
400 + 450 + 450 + 500 + 60 = 1860 mL
Balance
B = 1500 − 1860 = −360 mL
Answer
B = −360 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: t = 3 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
1000 − 550 = 450 mL
Time
t = 450/150 = 3 h
Answer
t = 3 h
That is about 3 h 00 min, so the bag runs out at about 19:00.
35.Clinical assessment scores
Answer: SI = 0.55
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Shock index
SI = 83/151 = 0.5497 ≈ 0.55
Answer
SI = 0.55
Within or below the usual 0.5–0.7.
36.Clinical assessment scores
Answer: obesity class III
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 121/1.65² = 44.44
Category
obesity class III
Answer
obesity class III
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 7.22: acidaemia (below 7.35)
PaCO₂ 79 mmHg: high (35–45)
HCO₃⁻ 31 mmol/L: high (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: A–a gradient = 212.5 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Alveolar oxygen
PAO₂ = 0.5·713 − 52/0.8 = 356.5 − 65 = 291.5 mmHg
Gradient
A–a = 291.5 − 79 = 212.5 mmHg
Answer
A–a gradient = 212.5 mmHg
39.ECG rhythm strip interpretation
Answer: sinus rhythm with sinus arrest
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: 6 QRS complexes in 6 s, × 10 = 60 per minute.
2. Rhythm: regular (R–R 0.84 s) except for one pause of 1.96 s, which is not a whole number of P–P cycles.
3. P waves: upright, one before every QRS; no P wave at all during the pause.
4. PR interval: 0.14 s, constant, within 0.12–0.20 s.
5. QRS: 0.10 s, narrow (below 0.12 s).
Interpretation
sinus rhythm with sinus arrest
Answer
sinus rhythm with sinus arrest
40.ECG rhythm strip interpretation
Answer: ventricular paced rhythm
Paced rhythms: a pacemaker impulse shows as a narrow vertical pacing spike. After a ventricular spike the QRS is wide (0.12 s or more), because the impulse spreads from the lead through the muscle instead of the conduction system; with right-ventricular pacing it is often mostly negative in lead II. A spike before each P wave means atrial pacing, and a dual-chamber (AV) pacemaker shows an atrial spike and a P wave, then, after the programmed AV delay, a ventricular spike and a wide QRS. Capture means every spike is followed by a depolarisation. Failure to capture is a spike without a P wave or QRS after it; failure to sense (spikes that ignore the patient’s own beats) and failure to pace (no spike when one is due) are the other classic malfunctions.
Five steps
1. Rate: R–R = 25 small boxes, 1500 ÷ 25 ≈ 60 per minute.
2. Rhythm: regular, every R–R is 1.00 s.
3. P waves: none visible; a sharp pacing spike comes just before every QRS.
4. PR interval: not measurable.
5. QRS: 0.14 s, wide, and every spike is followed by a QRS (capture).
Interpretation
ventricular paced rhythm
Answer
ventricular paced rhythm
The paced QRS is wide by nature; do not call it a bundle branch block or a ventricular rhythm.
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