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
What does the Visual Infusion Phlebitis (VIP) score assess?
AThe risk of an allergic reaction to IV drugs
BThe patient's eyesight before surgery
CThe cannula site for signs of phlebitis
DThe speed of an infusion pump
2.Nursing fundamentalsHard
A patient with COPD and a known risk of hypercapnia is acutely breathless with an SpO₂ of 82%. What is correct?
AGive the highest oxygen flow possible and aim for 100%
BWithhold oxygen completely, because oxygen is dangerous in COPD
CGive controlled oxygen, e.g. via a Venturi mask, aiming for 88–92%
DWait for an arterial blood gas result before giving any oxygen at all
3.Infection control & patient safetyMedium
A nurse wants to set up a sterile field in the morning for a procedure that will take place after lunch. What is correct?
ASet it up in the morning and leave it uncovered in an empty room
BSet it up in the morning and cover it with a clean towel until the procedure starts
CSet it up just before the procedure, because a waiting field may become contaminated
DSet it up in the morning and ask a colleague to check it once
4.Infection control & patient safetyHard
A nurse teaches a patient going home with an MRSA wound infection. Which statement shows a need for further teaching?
A“I will put used dressings in a sealed bag before throwing them out.”
B“I can share towels with my family if I wash them every week.”
C“I will keep the wound covered with a clean, dry dressing.”
D“I will wash my hands after touching my dressing.”
5.Prioritization & delegationMedium
A nurse teaches a patient who uses crutches. Which statement shows a need for further teaching?
A“I will keep the crutch tips in good condition.”
B“I will take my weight on my hands, not on my armpits.”
C“I will remove loose rugs from the floor at home.”
D“I will lean on the crutch pads under my arms to rest.”
6.Prioritization & delegationHard
Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?
AAn anticholinergic drug, such as benztropine or procyclidine, as prescribed
BPhysical restraint until the spasm passes
CNo action, because the spasm is a sign of improvement
DA higher dose of haloperidol to calm the patient and stop the movements quickly
7.Clinical nursingMedium
A patient is admitted with cellulitis of the leg. Why might the nurse mark the edge of the redness on the skin?
ATo monitor whether the infection is spreading or improving
BTo show the surgeon exactly where to make the incision
CTo help the patient find the sore area
DTo mark the site for an injection
8.Clinical nursingHard
An acutely ill patient without COPD is on 15 L/min oxygen, and their SpO2 is now 100% and stable. What should be done?
AIncrease the oxygen further to build up a reserve
BKeep the oxygen at 15 L/min for at least a week to be on the safe side
CReduce the oxygen to keep the SpO2 within the prescribed target range
DStop the oxygen and the saturation monitoring because the patient is now well
9.Lab values & electrolytesMedium
When should a blood specimen tube be labeled?
ABefore entering the room, so tubes are ready for the next patients
BIn the laboratory, by the staff who receive the unlabeled sample
CAt the nurses' station, after all samples for the shift are drawn
DAt the bedside, in the patient's presence, using two identifiers
10.Lab values & electrolytesHard
A patient arrives 30 minutes after vomiting a large amount of blood. The heart rate is 125/min, but the first hemoglobin is 13.0 g/dL (130 g/L). Why is the hemoglobin misleading?
AWhole blood is lost, so the level falls only hours later
BThe test is never accurate in emergency situations
CHemoglobin rises during bleeding, which hides the loss
DThe value proves there is no significant bleeding
11.PharmacologyMedium
How does clopidogrel reduce platelet aggregation?
AIt activates antithrombin
BIt inhibits platelet COX-1
CIt blocks the platelet P2Y12 receptor for ADP
DIt blocks the glycoprotein IIb/IIIa receptor directly
12.PharmacologyHard
Why are patients on long-acting nitrates advised to have a nitrate-free period of several hours each day?
ATo prevent tolerance to the nitrate
BTo reduce the risk of bleeding
CTo let the liver recover from toxicity
DTo avoid nitrate accumulation in fat tissue
13.Med-surg: cardiovascular & respiratoryMedium
Why should a simple face mask not be used with an oxygen flow below about 5 L/min?
AThe elastic strap is too loose at low flows
BExhaled CO₂ can collect in the mask and be rebreathed
COxygen cannot be humidified at low flows
DThe mask delivers too much oxygen at low flows
14.Med-surg: cardiovascular & respiratoryHard
During a cardiac arrest, the monitor shows an organised rhythm, but there is no pulse. What should the team do?
AGive adenosine to slow the rhythm down
BStop CPR, because an organised rhythm on the monitor means recovery
CContinue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
DDeliver an unsynchronised shock at once and then check the pulse
15.Med-surg: neuro, endocrine & renalMedium
What is the main purpose of continuous bladder irrigation after a transurethral resection of the prostate (TURP)?
ATo give the patient extra fluids
BTo stop blood clots from blocking the catheter
CTo treat a urinary infection after the operation
DTo measure the size of the bladder
16.Med-surg: neuro, endocrine & renalHard
The nurse has four renal patients. Which one needs to be seen first?
AA patient with CKD asking about their phosphate binder
BA patient with a potassium of 6.8 mmol/L who reports palpitations
CA patient with mild itching from uraemia who wants a cream
DA patient with a creatinine slightly above their usual level
17.Med-surg: GI, perioperative & oncologyMedium
Why do patients with major burns lose so much fluid in the first 24–48 hours?
APatients drink far too little in hospital in the first days
BLeaky capillaries let plasma move into the tissues
CThe burned skin absorbs fluid from the air
DThe kidneys stop making urine completely
18.Med-surg: GI, perioperative & oncologyHard
A patient receiving filgrastim (G-CSF) after chemotherapy asks which side effect to expect. Which side effect is most common?
AAching bone pain, as the bone marrow is stimulated
BA rapid fall in the white cell count
CComplete hair loss within days of the first injection
DPermanent hearing loss
19.Maternity & obstetric nursingMedium
Which substance in amniotic fluid is used to judge fetal lung maturity?
ABilirubin, assessed by its colour
BGlucose, assessed by its concentration
CAlpha-fetoprotein, assessed by its level
DSurfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
20.Maternity & obstetric nursingHard
A woman has just been diagnosed with gestational diabetes at 26 weeks. What is the usual first step in management?
AStart insulin or an oral sulfonylurea straight away for every woman, whatever her blood glucose readings show
BNo follow-up is needed until after birth
CStop eating all carbohydrates
DNutrition advice, physical activity and blood glucose monitoring, with medication if targets are not met
21.Pediatric nursingMedium
How should a nurse prepare a 4-year-old for a procedure?
AGive a detailed explanation a week in advance
BShow diagrams of the internal organs
CExplain shortly beforehand in simple words, and let the child handle the equipment or play with a doll
DExplain nothing to avoid frightening the child
22.Pediatric nursingHard
A 3-month-old has large, flat, blue-grey patches over the lower back and buttocks. The parents say they have been there since birth. What is the best action?
ARequest urgent clotting tests and a full blood count to look for a bleeding disorder
BReport them straight away to the safeguarding team as suspected physical abuse
CApply cold packs several times a day to reduce the discoloration
DDocument them with size and location as congenital dermal melanocytosis (Mongolian spots)
23.Mental health nursingMedium
Which statement about buspirone for anxiety is correct?
AIt must be taken with alcohol
BIt takes weeks to work and is not useful as an as-needed drug
CIt works within minutes during a panic attack, like a benzodiazepine
DIt is highly addictive
24.Mental health nursingHard
A nurse teaches a family member how to use a naloxone kit. Which statement shows a need for further teaching?
A"If he doesn't respond, I may need to give a second dose."
B"Once I've given the naloxone, I don't need to call an ambulance."
C"I'll stay with him, because the overdose can come back."
D"I'll check his breathing and put him in the recovery position if he is breathing but still not awake."
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 181 cm tall. Using 1 in = 2.54 cm, find the height h in inches. Round to one decimal place.
181 cm1 in = 2.54 cm
h = in
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A haemoglobin result is 110 g/L. Express it in g/dL Hb.
110 g/L1 L = 10 dL
Hb = g/dL
27.Dosage calculationsMedium
A child weighing 23 kg is prescribed 2 mg/kg of a drug. The stock solution contains 10 mg/mL. Draw up the dose: what volume V do you give?
23 kg2 mg/kg10 mg/mL
V = mL
28.Dosage calculationsHard
The prescription is 2840 micrograms. The ampoule contains 4 mg/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
2840 mcg4 mg/mL
V = mL
29.IV infusion ratesMedium
1000 mL was ordered over 6 hours. After 2 hours you find that 770 mL is still in the bag, and the order must still finish on time. To what rate R in mL/h must the pump be reset?
1000 mL / 6 hafter 2 h: 770 mL
R = mL/h
30.IV infusion ratesHard
An infusion of 400 mg in 500 mL runs at 20 mL/h. How many micrograms per minute D does the patient receive?
400 mg/500 mL20 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 100 units of regular insulin in 250 mL runs at 3 mL/h. How many units per hour D does the patient receive?
100 units/250 mL3 mL/h
D = units/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 21 mL/h. The patient weighs 110 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL21 mL/h110 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 patient weighs 74 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 1000 mL bag runs by pump at 80 mL/h. At 20:30, 200 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL200 mL infused80 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: no impairment; moisture: very moist; activity: bedfast; mobility: very limited; nutrition: very poor; friction and shear: potential problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 60 kg and is 184 cm tall. Calculate the BMI and click the WHO weight category.
60 kg184 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 16 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 16 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.17, PaCO₂ 17 mmHg (2.3 kPa), HCO₃⁻ 6 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.17PaCO₂ 17 mmHg (2.3 kPa)HCO₃⁻ 6 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
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
1sinus tachycardia
2supraventricular tachycardia (SVT)
3atrial fibrillation
4sinus bradycardia
40.ECG rhythm strip interpretationHard
Identify the rhythm on this 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
1ventricular fibrillation
2torsades de pointes
3atrial flutter, 2:1 conduction
4idioventricular rhythm
3Solutions
1.Nursing fundamentals
Answer: C · The cannula site for signs of phlebitis
Why this is the answer
The VIP score grades pain, redness, swelling and hardening along the vein. A rising score tells the nurse when the cannula must be removed.
Answer
C · The cannula site for signs of phlebitis
2.Nursing fundamentals
Answer: C · Give controlled oxygen, e.g. via a Venturi mask, aiming for 88–92%
Why this is the answer
Oxygen must not be withheld from a hypoxic patient. In those at risk of hypercapnia it is given in a controlled way to a target of 88–92%, with blood gases checked.
Answer
C · Give controlled oxygen, e.g. via a Venturi mask, aiming for 88–92%
3.Infection control & patient safety
Answer: C · Set it up just before the procedure, because a waiting field may become contaminated
Why this is the answer
The longer a sterile field is exposed, the more likely it is to be contaminated, and an unattended field cannot be considered sterile. It is prepared just before use.
Answer
C · Set it up just before the procedure, because a waiting field may become contaminated
4.Infection control & patient safety
Answer: B · “I can share towels with my family if I wash them every week.”
Why this is the answer
MRSA spreads by direct contact and shared items, so towels, razors and linen should not be shared. Hand hygiene, covering the wound and bagging dressings are correct.
Answer
B · “I can share towels with my family if I wash them every week.”
5.Prioritization & delegation
Answer: D · “I will lean on the crutch pads under my arms to rest.”
Why this is the answer
Leaning on the axillary pads can compress the nerves in the armpit. Weight should be taken through the hands, and the home should be made safe from trip hazards.
Answer
D · “I will lean on the crutch pads under my arms to rest.”
6.Prioritization & delegation
Answer: A · An anticholinergic drug, such as benztropine or procyclidine, as prescribed
Why this is the answer
Acute dystonia is an early extrapyramidal effect of antipsychotics. It responds quickly to an anticholinergic drug; it can be frightening, and laryngeal spasm can threaten the airway.
Answer
A · An anticholinergic drug, such as benztropine or procyclidine, as prescribed
7.Clinical nursing
Answer: A · To monitor whether the infection is spreading or improving
Why this is the answer
Marking the margin helps staff see whether the redness is spreading despite treatment, which may mean antibiotics need review. The limb is also elevated and observations monitored.
Answer
A · To monitor whether the infection is spreading or improving
8.Clinical nursing
Answer: C · Reduce the oxygen to keep the SpO2 within the prescribed target range
Why this is the answer
Oxygen is prescribed to a target range, usually 94–98% for most patients. Once the patient is stable it should be weaned down, as unnecessary hyperoxia has no benefit and can be harmful.
Answer
C · Reduce the oxygen to keep the SpO2 within the prescribed target range
9.Lab values & electrolytes
Answer: D · At the bedside, in the patient's presence, using two identifiers
Why this is the answer
Specimens are labeled immediately after collection, at the bedside, after checking two patient identifiers such as name and date of birth. Pre-labeling or labeling away from the patient can put the wrong patient's name on the sample, which can lead to harmful decisions.
Answer
D · At the bedside, in the patient's presence, using two identifiers
10.Lab values & electrolytes
Answer: A · Whole blood is lost, so the level falls only hours later
Why this is the answer
Early in hemorrhage, red cells and plasma are lost together, so the concentration stays normal at first. The heart rate and blood pressure are better guides to blood loss in the first hours.
Answer
A · Whole blood is lost, so the level falls only hours later
11.Pharmacology
Answer: C · It blocks the platelet P2Y12 receptor for ADP
Why this is the answer
Clopidogrel is activated in the liver and irreversibly blocks the P2Y12 ADP receptor on platelets. It is often combined with aspirin after a heart attack or stent.
Answer
C · It blocks the platelet P2Y12 receptor for ADP
12.Pharmacology
Answer: A · To prevent tolerance to the nitrate
Why this is the answer
Tolerance to nitrates develops quickly with constant levels. An asymmetric dosing schedule or removing patches overnight keeps them effective.
Answer
A · To prevent tolerance to the nitrate
13.Med-surg: cardiovascular & respiratory
Answer: B · Exhaled CO₂ can collect in the mask and be rebreathed
Why this is the answer
Simple face masks need about 5–10 L/min to wash exhaled CO₂ out of the mask. At lower flows the patient may rebreathe CO₂; a nasal cannula is more appropriate for low flows.
Answer
B · Exhaled CO₂ can collect in the mask and be rebreathed
14.Med-surg: cardiovascular & respiratory
Answer: C · Continue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
Why this is the answer
Pulseless electrical activity is a non-shockable rhythm. Treatment is high-quality CPR, adrenaline as soon as possible and repeated, and a search for reversible causes (the 4 Hs and 4 Ts, such as hypoxia, hypovolaemia, tension pneumothorax and tamponade). Shocks are only for VF and pulseless VT.
Answer
C · Continue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
15.Med-surg: neuro, endocrine & renal
Answer: B · To stop blood clots from blocking the catheter
Why this is the answer
After TURP, the raw prostate bed bleeds, and clots can block the catheter and cause retention and bladder spasms. Continuous irrigation through a three-way catheter keeps the drainage flowing.
Answer
B · To stop blood clots from blocking the catheter
16.Med-surg: neuro, endocrine & renal
Answer: B · A patient with a potassium of 6.8 mmol/L who reports palpitations
Why this is the answer
Severe hyperkalaemia with palpitations may lead to life-threatening arrhythmias and needs an urgent ECG, cardiac monitoring and treatment. The other problems are stable or less urgent.
Answer
B · A patient with a potassium of 6.8 mmol/L who reports palpitations
17.Med-surg: GI, perioperative & oncology
Answer: B · Leaky capillaries let plasma move into the tissues
Why this is the answer
Inflammatory mediators make capillaries leaky, so plasma moves into the tissues and from the burn surface. Without fluids this causes burn shock; oedema is greatest in the first day or two.
Answer
B · Leaky capillaries let plasma move into the tissues
18.Med-surg: GI, perioperative & oncology
Answer: A · Aching bone pain, as the bone marrow is stimulated
Why this is the answer
Granulocyte colony-stimulating factors stimulate the marrow to make neutrophils, which often causes aching bone pain, especially in the back, pelvis and long bones; it is usually managed with simple analgesia as prescribed. A rare but serious effect is splenic rupture, so new left upper abdominal or shoulder-tip pain must be reported at once.
Answer
A · Aching bone pain, as the bone marrow is stimulated
19.Maternity & obstetric nursing
Answer: D · Surfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
Why this is the answer
Surfactant reduces surface tension and keeps alveoli open. An L/S ratio of about 2:1 or more suggests the lungs are mature. Amniotic fluid testing for lung maturity is now rarely used in practice.
Answer
D · Surfactant, assessed by the lecithin/sphingomyelin (L/S) ratio
20.Maternity & obstetric nursing
Answer: D · Nutrition advice, physical activity and blood glucose monitoring, with medication if targets are not met
Why this is the answer
First-line management is medical nutrition therapy, activity and self-monitoring of glucose. If targets are not met, medication such as insulin is added. Glucose is tested again after birth because the risk of type 2 diabetes is raised.
Answer
D · Nutrition advice, physical activity and blood glucose monitoring, with medication if targets are not met
21.Pediatric nursing
Answer: C · Explain shortly beforehand in simple words, and let the child handle the equipment or play with a doll
Why this is the answer
Preschoolers do best with short, concrete explanations just before the procedure and with medical play. Long advance warnings increase fear, and diagrams are better for school-age children.
Answer
C · Explain shortly beforehand in simple words, and let the child handle the equipment or play with a doll
22.Pediatric nursing
Answer: D · Document them with size and location as congenital dermal melanocytosis (Mongolian spots)
Why this is the answer
Congenital dermal melanocytosis is a common benign birthmark, especially in babies with darker skin. Careful documentation from early on helps prevent it later being mistaken for bruising; the marks usually fade during childhood.
Answer
D · Document them with size and location as congenital dermal melanocytosis (Mongolian spots)
23.Mental health nursing
Answer: B · It takes weeks to work and is not useful as an as-needed drug
Why this is the answer
Buspirone has little sedation and low dependence risk, but its effect builds up over weeks. It is taken regularly, not as needed.
Answer
B · It takes weeks to work and is not useful as an as-needed drug
24.Mental health nursing
Answer: B · "Once I've given the naloxone, I don't need to call an ambulance."
Why this is the answer
Naloxone is short-acting, so the opioid effect can return. Emergency services must always be called, and the person must be watched until help arrives.
Answer
B · "Once I've given the naloxone, I don't need to call an ambulance."
25.Nursing math & unit conversions
Answer: h = 71.3 in
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.
Centimetres to inches
h = 181/2.54 = 71.26 ≈ 71.3 in
Answer
h = 71.3 in
26.Nursing math & unit conversions
Answer: Hb = 11 g/dL
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.
Convert
Hb = 110 g/L × (1 L/10 dL) = 11 g/dL
Answer
Hb = 11 g/dL
27.Dosage calculations
Answer: V = 4.6 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 2·23 = 46 mg
Volume
V = 46/10 = 4.6 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4.6 mL
28.Dosage calculations
Answer: V = 0.71 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.
Same units
4 mg/mL = 4000 mcg/mL
Volume
V = 2840/4000 = 0.71 mL
Answer
V = 0.71 mL
29.IV infusion rates
Answer: R = 192.5 mL/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
1000/6 = 166.7 mL/h
New rate
R = 770/4 = 192.5 mL/h
Answer
R = 192.5 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: D = 266.7 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
400000 mcg/500 mL = 800 mcg/mL
Dose per hour
20·800 = 16000 mcg/h
Dose per minute
D = 16000/60 = 266.7 mcg/min
Answer
D = 266.7 mcg/min
31.Pediatric & critical-care dosing
Answer: D = 1.2 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
100/250 = 0.4 units/mL
Units per hour
D = 3·0.4 = 1.2 units/h
Answer
D = 1.2 units/h
32.Pediatric & critical-care dosing
Answer: D = 3.2 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
21·1000 = 21000 mcg/h
21000/60 = 350 mcg/min
Per kilogram
D = 350/110 = 3.182 ≈ 3.2 mcg/kg/min
Answer
D = 3.2 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 1.48 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
250 + 400 + 225 = 875 mL
Per kilogram per hour
U = 875/(74·8) = 1.478 ≈ 1.48 mL/kg/h
Answer
U = 1.48 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 10 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 − 200 = 800 mL
Time
t = 800/80 = 10 h
Answer
t = 10 h
That is about 10 h 00 min, so the bag runs out at about 06:30.
35.Clinical assessment scores
Answer: B = 12
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: no impairment → 4
moisture: very moist → 2
activity: bedfast → 1
mobility: very limited → 2
nutrition: very poor → 1
friction and shear: potential problem → 2
Add
Braden total = 4 + 2 + 1 + 2 + 1 + 2 = 12
Answer
B = 12
36.Clinical assessment scores
Answer: underweight
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 = 60/1.84² = 17.72
Category
underweight
Answer
underweight
37.Arterial blood gas interpretation
Answer: PaCO₂ = 32 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Winter’s formula
PaCO₂ = 1.5·16 + 8 = 32 mmHg
range: 30–34 mmHg
Answer
PaCO₂ = 32 mmHg
38.Arterial blood gas interpretation
Answer: appropriate compensation
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
1.5·6 + 8 = 17 → 15–19 mmHg
Compare
measured: 17 mmHg → appropriate compensation
Answer
appropriate compensation
39.ECG rhythm strip interpretation
Answer: sinus tachycardia
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: R–R = 14 small boxes, 1500 ÷ 14 ≈ 107 per minute.
2. Rhythm: regular, every R–R is 0.56 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.12 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
sinus tachycardia
Answer
sinus tachycardia
40.ECG rhythm strip interpretation
Answer: torsades de pointes
More ventricular rhythms: torsades de pointes is a polymorphic ventricular tachycardia, usually 150–250/min, in which the wide complexes change in height and twist around the baseline, pointing up for a few beats and then down. Textbooks link it to a prolonged QT interval, and magnesium sulfate is the drug resuscitation guidelines name for it. An idioventricular rhythm is a ventricular escape rhythm: regular, wide QRS (0.12 s or more), no P waves, at 20–40/min (an accelerated idioventricular rhythm runs at 40–100/min). Monomorphic VT has identical wide complexes at more than 100/min. VF is chaotic, without any repeating complex.
Five steps
1. Rate: very fast, the complexes are about 7 small boxes apart (about 214 per minute).
2. Rhythm: fast and roughly regular, but the height and direction of the complexes change in a repeating spindle pattern.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: wide and polymorphic; the complexes twist around the baseline, pointing up for a few beats and then down.
Interpretation
torsades de pointes
Answer
torsades de pointes
Torsades de pointes is a polymorphic VT linked to a prolonged QT interval. This is identification practice only.
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