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
In the UK SSKIN care bundle for pressure ulcer prevention, what does "K" stand for?
AKeep clean
BKeep dry
CKeep moving
DKeep warm
2.Nursing fundamentalsHard
A patient with capacity tells the nurse they do not want the operation their family keeps pushing for. What is the nurse's best action?
ASupport the patient to tell the team their wishes
BTell the patient to follow the family's advice
CLet the family decide, as they know the patient best
DSay nothing to avoid a conflict with the family
3.Infection control & patient safetyMedium
A patient’s identification wristband is missing. A medication is due. What should the nurse do?
ASkip the medication until the next day
BUse the room and bed number to confirm identity
CGive it, because the nurse recognizes the patient from yesterday
DConfirm identity with two identifiers and apply a new wristband first
4.Infection control & patient safetyHard
A patient rescued from a house fire has a headache and confusion, but the pulse oximeter reads 99%. Why might this reading be misleading?
AConfusion and headache make pulse oximetry readings inaccurate in every patient
BPulse oximeters always read falsely low after any kind of smoke exposure
CPulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
DThe reading is accurate, so carbon monoxide poisoning is ruled out
5.Prioritization & delegationMedium
A patient has a serum potassium of 2.9 mEq/L. Which finding should the nurse expect?
AA rise in urine output and thirst only
BMuscle weakness and U waves on the ECG
CTall, peaked T waves and muscle twitching
DFlushed, warm skin and a slow heart rate
6.Prioritization & delegationHard
A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?
AAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
BGive the as-needed sedative so the patient rests comfortably
CLet the patient sleep, because the saturation is above target
DIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
7.Clinical nursingMedium
A patient with heart failure gains 2 kg in two days. What does this most likely indicate?
ASuccessful treatment
BDehydration
CFluid retention
DIncreased muscle mass
8.Clinical nursingHard
The fluid in an underwater seal chest drain has stopped swinging with breathing. What could this mean?
AThe patient's breathing has become normal and the drain can be pulled out by the nurse
BThe drain is working perfectly and needs no checks
CThe tube may be kinked or blocked, or the lung may have fully re-expanded
DThe water seal has been set up correctly for the first time
9.Lab values & electrolytesMedium
Which factor is most likely to raise a patient’s lithium level?
ADehydration or a sudden drop in sodium intake
BEating more salt than usual for several days
CTaking each dose with a meal instead of before
DDrinking more fluid than usual in hot weather
10.Lab values & electrolytesHard
The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?
A"I'll blow my nose gently, not forcefully"
B"I'll use a soft-bristled toothbrush"
C"I'll take aspirin if I get a headache"
D"I'll use an electric razor to shave"
11.PharmacologyMedium
Why are benzodiazepines used with great caution in older people?
AThey cause permanent hearing loss in older people
BThey raise the risk of confusion, falls and fractures
CThey cause severe high blood pressure in older people
DThey are not absorbed from the gut after age 65
12.PharmacologyHard
A patient with myasthenia gravis took extra pyridostigmine doses. She now has increasing weakness, heavy salivation, sweating, small pupils and diarrhoea. What is the most likely cause?
ACholinergic crisis from too much anticholinesterase drug
BAn allergic reaction to pyridostigmine
CA stroke unrelated to the medication
DMyasthenic crisis from too little anticholinesterase drug
13.Med-surg: cardiovascular & respiratoryMedium
Which features best describe an arterial leg ulcer?
APainful, pale, punched-out ulcer on the toes with weak foot pulses
BPainless ulcer under the ball of the foot with thick callus around it
CWeeping ulcer on the shin with pitting oedema of the leg
DShallow, moist ulcer above the inner ankle with brown skin
14.Med-surg: cardiovascular & respiratoryHard
Which instruction from the registered nurse to a healthcare assistant (unlicensed assistive personnel) caring for a patient with COPD is most appropriate?
A"Listen to his chest after lunch and let me know what you can hear."
B"Tell me straight away if his SpO₂ is under 88% or he is more breathless."
C"Turn his oxygen up to whatever he needs if he looks short of breath."
D"Teach him how to use his new inhaler this afternoon after his rest."
15.Med-surg: neuro, endocrine & renalMedium
A patient taking carbimazole for hyperthyroidism reports a sore throat and fever. What should the nurse do?
AArrange an urgent full blood count to look for agranulocytosis
BDouble the dose to bring the thyroid under control faster
CAdvise salt-water gargles and continue the drug for a week
DReassure the patient, as the drug has no serious blood side effects
16.Med-surg: neuro, endocrine & renalHard
A patient on warfarin starts levothyroxine for hypothyroidism. What should the nurse expect to monitor more closely?
AThe INR, because it may rise
BThe urine output, because it may stop
CThe potassium, because it may rise
DThe blood glucose, because it may fall
17.Med-surg: GI, perioperative & oncologyMedium
What does "neoadjuvant" treatment mean?
ATreatment that is given instead of any surgery
BTreatment given only for pain relief
CTreatment before the main treatment, often to shrink the tumour
DTreatment that is given only after the cancer has already spread
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?
ARebound hypoglycaemia
BRaised intracranial pressure
CSevere hyperkalaemia
DAcute urinary retention
19.Maternity & obstetric nursingMedium
Why do newborns become cold so easily?
AThey sweat more than adults
BThey cannot produce heat at all
CTheir blood is thicker than adult blood
DThey have a large surface area and little fat
20.Maternity & obstetric nursingHard
A newborn is pale, has a heart rate of 170/min and weak pulses after a difficult vacuum birth. The scalp is boggy and swelling across the sutures is increasing. What should the nurse suspect?
ACaput succedaneum
BSimple cephalhaematoma
CNormal moulding
DSubgaleal haemorrhage
21.Pediatric nursingMedium
Why are codeine and tramadol not recommended for children under 12 years?
AThey can only be given intravenously
BThey are too weak to relieve moderate pain, so stronger opioids are always preferred
CSome children metabolise them very quickly, causing dangerous breathing depression
DThey always cause allergies
22.Pediatric nursingHard
Two weeks after a ventriculoperitoneal shunt was inserted, an infant has a fever, irritability and redness along the shunt tract. What should the nurse suspect?
AShunt infection; report it urgently
BTeething, which explains the fever and the irritability
CAn allergy to the hospital soap
DNormal healing; no action needed
23.Mental health nursingMedium
Which group of signs suggests drug-induced pseudoparkinsonism in a patient taking haloperidol?
ARestless pacing and an inability to sit still
BLip smacking, tongue thrusting and grimacing after years of treatment
CShuffling gait, mask-like face, rigidity and a resting tremor
DSudden muscle spasm of the neck with the eyes rolled upwards
24.Mental health nursingHard
A nurse is teaching a patient with anxiety how to do progressive muscle relaxation. Which instruction is correct?
AHold your breath for as long as possible while lying completely still on the floor
BTense each muscle group in turn for a few seconds, then let go and notice the difference
CTense all your muscles at once and keep them tight for 10 minutes
DDo the exercise only during a panic attack, never at other times
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 3:45 AM. Which entry is the same time on the 24-hour clock? Click it.
3:45 AM
102:45
215:45
303:45
404:45
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 1 tsp of an oral suspension twice a day for 7 days. Using 1 tsp = 5 mL, how many mL V are needed for the whole course?
1 tsptwice a day7 days1 tsp = 5 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 80 kg. The prescribed dose is 5 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
80 kg5 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
A child weighing 20 kg is prescribed 5 mg/kg per dose of an oral suspension that contains 250 mg in 5 mL. What volume V do you give?
20 kg5 mg/kg250 mg/5 mL
V = mL
29.IV infusion ratesMedium
500 mL was ordered over 12 hours. After 5 hours you find that 330 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?
500 mL / 12 hafter 5 h: 330 mL
R = mL/h
30.IV infusion ratesHard
An infusion of 25 mg in 250 mL runs at 5 mL/h. How many micrograms per minute D does the patient receive?
25 mg/250 mL5 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 16 units/kg/h for a patient who weighs 103 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL16 units/kg/h103 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dopamine infusion of 800 mg in 500 mL runs at 21 mL/h. The patient weighs 94 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
800 mg/500 mL21 mL/h94 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 12-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 infusion starts at 14:30 at 75 mL/h. After 4 hours the rate is changed to 50 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL75 mL/h · 4 h50 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 16/min, SpO₂ 99% on supplemental oxygen, blood pressure 124/74 mmHg, pulse 64/min, alert, temperature 37.3 °C. What is the NEWS2 total score?
RR 16SpO₂ 99%O₂SBP 124HR 64AT 37.3 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 14/min, SpO₂ 86% on room air, blood pressure 142/86 mmHg, pulse 70/min, alert, temperature 36.0 °C. Which clinical risk group does the patient fall into? Click it.
RR 14SpO₂ 86%airSBP 142HR 70AT 36.0 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 27 mmHg (3.6 kPa). Use the rule that in chronic respiratory alkalosis HCO₃⁻ falls by 5 mmol/L for every 10 mmHg that PaCO₂ is below 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a metabolic alkalosis with HCO₃⁻ 33 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 33 mmol/L
PaCO₂ = mmHg
39.ECG rhythm strip interpretationMedium
Measure the QT interval on this lead II strip, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QT = s
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
1junctional rhythm
2paced rhythm, failure to capture
3dual-chamber (AV) paced rhythm
4sinus rhythm with wide QRS
3Solutions
1.Nursing fundamentals
Answer: C · Keep moving
Why this is the answer
SSKIN stands for Surface, Skin inspection, Keep moving, Incontinence and moisture, and Nutrition and hydration. Regular repositioning relieves pressure on the skin.
Answer
C · Keep moving
2.Nursing fundamentals
Answer: A · Support the patient to tell the team their wishes
Why this is the answer
As an advocate the nurse makes sure the patient's own wishes are heard. A competent adult decides about their treatment, and the family's views do not override this.
Answer
A · Support the patient to tell the team their wishes
3.Infection control & patient safety
Answer: D · Confirm identity with two identifiers and apply a new wristband first
Why this is the answer
Every medication requires a confirmed identity. The nurse replaces the wristband after confirming the patient’s identity with two identifiers. Familiarity and room numbers are not acceptable identifiers.
Answer
D · Confirm identity with two identifiers and apply a new wristband first
4.Infection control & patient safety
Answer: C · Pulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
Why this is the answer
Standard pulse oximeters read carboxyhemoglobin as oxyhemoglobin, so SpO2 can look normal in carbon monoxide poisoning. A blood carboxyhemoglobin level confirms it, and high-flow oxygen is given.
Answer
C · Pulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
5.Prioritization & delegation
Answer: B · Muscle weakness and U waves on the ECG
Why this is the answer
Hypokalemia causes muscle weakness, cramps and arrhythmias, with flattened T waves and U waves on the ECG. Peaked T waves are a sign of hyperkalemia.
Answer
B · Muscle weakness and U waves on the ECG
6.Prioritization & delegation
Answer: A · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
Why this is the answer
In COPD, drowsiness can be a sign of carbon dioxide retention (hypercapnia), even when the saturation is acceptable. The nurse assesses breathing, escalates and avoids extra oxygen or sedatives that could worsen it.
Answer
A · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
7.Clinical nursing
Answer: C · Fluid retention
Why this is the answer
Sudden weight gain in heart failure usually means fluid overload. Daily weights are the simplest way to track fluid balance.
Answer
C · Fluid retention
8.Clinical nursing
Answer: C · The tube may be kinked or blocked, or the lung may have fully re-expanded
Why this is the answer
Loss of swing can mean a kinked, clamped or blocked tube, or re-expansion of the lung. The nurse checks the tubing and the patient and reports the finding.
Answer
C · The tube may be kinked or blocked, or the lung may have fully re-expanded
9.Lab values & electrolytes
Answer: A · Dehydration or a sudden drop in sodium intake
Why this is the answer
When the body is short of sodium or water, the kidneys keep more sodium and lithium with it, so the level rises. NSAIDs, thiazide diuretics and ACE inhibitors can also raise lithium levels.
Answer
A · Dehydration or a sudden drop in sodium intake
10.Lab values & electrolytes
Answer: C · "I'll take aspirin if I get a headache"
Why this is the answer
Aspirin irreversibly inhibits platelet function and raises the bleeding risk further in thrombocytopenia, so it and other NSAIDs are avoided unless prescribed. An electric razor, gentle nose blowing and a soft toothbrush reduce minor bleeding.Checked against:Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Aspirin · MedlinePlus (NIH) (2025)
Answer
C · "I'll take aspirin if I get a headache"
11.Pharmacology
Answer: B · They raise the risk of confusion, falls and fractures
Why this is the answer
Older people are more sensitive to benzodiazepines and often eliminate them more slowly. Sedation, unsteadiness and confusion raise the risk of falls and fractures.
Answer
B · They raise the risk of confusion, falls and fractures
12.Pharmacology
Answer: A · Cholinergic crisis from too much anticholinesterase drug
Why this is the answer
Excess acetylcholine causes muscarinic signs (salivation, sweating, miosis, diarrhoea) and depolarising weakness. In myasthenic crisis, weakness occurs without these cholinergic signs; both can cause respiratory failure.
Answer
A · Cholinergic crisis from too much anticholinesterase drug
13.Med-surg: cardiovascular & respiratory
Answer: A · Painful, pale, punched-out ulcer on the toes with weak foot pulses
Why this is the answer
Arterial ulcers result from ischaemia: deep, well defined, pale or necrotic and painful, on toes, heels or pressure points, with cool, hairless skin and weak pulses. Shallow moist ulcers near the inner ankle are venous, and painless plantar ulcers with callus are typically neuropathic (diabetic).
Answer
A · Painful, pale, punched-out ulcer on the toes with weak foot pulses
14.Med-surg: cardiovascular & respiratory
Answer: B · "Tell me straight away if his SpO₂ is under 88% or he is more breathless."
Why this is the answer
Delegated tasks should come with specific parameters for reporting. Changing oxygen therapy, chest assessment and patient teaching need a registered nurse's knowledge and judgement. Clear reporting instructions keep the patient safe.
Answer
B · "Tell me straight away if his SpO₂ is under 88% or he is more breathless."
15.Med-surg: neuro, endocrine & renal
Answer: A · Arrange an urgent full blood count to look for agranulocytosis
Why this is the answer
Thionamides (carbimazole, methimazole, propylthiouracil) can cause agranulocytosis, a rare but life-threatening fall in neutrophils. Patients are taught to report sore throat, fever or mouth ulcers immediately and have an urgent blood count; the drug is stopped if neutrophils are low.
Answer
A · Arrange an urgent full blood count to look for agranulocytosis
16.Med-surg: neuro, endocrine & renal
Answer: A · The INR, because it may rise
Why this is the answer
As thyroid function returns to normal, clotting factors are broken down faster, which increases the effect of warfarin. The INR is checked more often and the warfarin dose may need to be reduced.
Answer
A · The INR, because it may rise
17.Med-surg: GI, perioperative & oncology
Answer: C · Treatment before the main treatment, often to shrink the tumour
Why this is the answer
Neoadjuvant chemotherapy or radiotherapy is given before surgery to shrink the tumour, which may make surgery easier or allow less extensive surgery. Adjuvant therapy follows surgery.
Answer
C · Treatment before the main treatment, often to shrink the tumour
18.Med-surg: GI, perioperative & oncology
Answer: A · 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
A · Rebound hypoglycaemia
19.Maternity & obstetric nursing
Answer: D · They have a large surface area and little fat
Why this is the answer
Newborns have a large surface area relative to body mass, little subcutaneous fat and thin skin with blood vessels near the surface. They rely on brown fat and cannot shiver effectively.
Answer
D · They have a large surface area and little fat
20.Maternity & obstetric nursing
Answer: D · Subgaleal haemorrhage
Why this is the answer
A subgaleal haemorrhage is bleeding under the scalp aponeurosis. It crosses suture lines, can grow rapidly and can cause hypovolaemic shock. It is an emergency, unlike caput or cephalhaematoma.
Answer
D · Subgaleal haemorrhage
21.Pediatric nursing
Answer: C · 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
C · Some children metabolise them very quickly, causing dangerous breathing depression
22.Pediatric nursing
Answer: A · Shunt infection; report it urgently
Why this is the answer
Shunt infections usually occur within the first months after surgery and may show fever, redness or swelling along the tract, poor feeding and irritability, sometimes with signs of shunt blockage. Urgent assessment, cultures and antibiotics are needed.
Answer
A · Shunt infection; report it urgently
23.Mental health nursing
Answer: C · Shuffling gait, mask-like face, rigidity and a resting tremor
Why this is the answer
Blocking dopamine in the nigrostriatal pathway can cause parkinsonian signs: bradykinesia, rigidity, tremor and a shuffling gait. The other options describe akathisia, acute dystonia and tardive dyskinesia.
Answer
C · Shuffling gait, mask-like face, rigidity and a resting tremor
24.Mental health nursing
Answer: B · Tense each muscle group in turn for a few seconds, then let go and notice the difference
Why this is the answer
Progressive muscle relaxation involves tensing and then relaxing muscle groups in turn. Regular practice when calm makes it easier to use the skill when anxious.
Answer
B · Tense each muscle group in turn for a few seconds, then let go and notice the difference
25.Nursing math & unit conversions
Answer: 03:45
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
3 AM → 03
Answer
03:45
Answer
03:45
26.Nursing math & unit conversions
Answer: V = 70 mL
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.
Volume per dose
1 tsp = 1·5 = 5 mL
Whole course
V = 5 mL × 2/day × 7 = 70 mL
Answer
V = 70 mL
27.Dosage calculations
Answer: D = 200 mg
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Total per day
5·80 = 400 mg
Per dose
D = 400/2 = 200 mg
Answer
D = 200 mg
28.Dosage calculations
Answer: V = 2 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose from weight
5·20 = 100 mg
Volume
V = (100/250)·5 = 2 mL
Answer
V = 2 mL
29.IV infusion rates
Answer: R = 47.14 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
500/12 = 41.67 mL/h
New rate
R = 330/7 = 47.14 mL/h
Answer
R = 47.14 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: D = 8.333 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
25000 mcg/250 mL = 100 mcg/mL
Dose per hour
5·100 = 500 mcg/h
Dose per minute
D = 500/60 = 8.333 mcg/min
Answer
D = 8.333 mcg/min
31.Pediatric & critical-care dosing
Answer: R = 16.5 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
16·103 = 1 648 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1648/100 = 16.48 ≈ 16.5 mL/h
Answer
R = 16.5 mL/h
32.Pediatric & critical-care dosing
Answer: D = 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
800 000/500 = 1600 mcg/mL
Micrograms per minute
21·1600 = 33600 mcg/h
33600/60 = 560 mcg/min
Per kilogram
D = 560/94 = 5.957 ≈ 6 mcg/kg/min
Answer
D = 6 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = 915 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: 100 + 200 = 300 mL
IV infusion: 125·12 = 1500 mL
IV antibiotic: 1·100 = 100 mL
total intake = 1900 mL
Total output
475 + 400 + 110 = 985 mL
Balance
B = 1900 − 985 = 915 mL
Answer
B = 915 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 18 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
75·4 = 300 mL
1000 − 300 = 700 mL left
Second part
700/50 = 14 h
Total time
t = 4 + 14 = 18 h
Answer
t = 18 h
That is about 18 h 00 min, so the bag runs out at about 08:30.
35.Clinical assessment scores
Answer: NEWS2 = 2
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 16/min → 0
SpO₂ 99% → 0
on oxygen → 2
SBP 124 mmHg → 0
HR 64/min → 0
alert (A) → 0
T 37.3 °C → 0
Add
NEWS2 = 0 + 0 + 2 + 0 + 0 + 0 + 0 = 2
Answer
NEWS2 = 2
36.Clinical assessment scores
Answer: low–medium
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 14/min → 0
SpO₂ 86% → 3
on air → 0
SBP 142 mmHg → 0
HR 70/min → 0
alert (A) → 0
T 36.0 °C → 1
Total and red scores
NEWS2 = 0 + 3 + 0 + 0 + 0 + 0 + 1 = 4
At least one parameter scores 3.
Risk group
low–medium
Answer
low–medium
A single score of 3 needs an urgent review even when the total is low.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 17.5 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.
Change in PaCO₂
|27 − 40| = 13 mmHg → 1.3 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 − 5·1.3 = 17.5 mmol/L
Answer
HCO₃⁻ = 17.5 mmol/L
38.Arterial blood gas interpretation
Answer: PaCO₂ = 44.1 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
0.7·33 + 21 = 44.1 mmHg
Answer
PaCO₂ = 44.1 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: QT = 0.38 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
9.5 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 9.5 × 0.04 s = 0.38 s
Answer
QT = 0.38 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 0.72 s).
40.ECG rhythm strip interpretation
Answer: dual-chamber (AV) 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 = 24 small boxes, 1500 ÷ 24 ≈ 63 per minute.
2. Rhythm: regular, every R–R is 0.96 s.
3. P waves: each P wave follows its own pacing spike (atrial pacing).
4. AV interval: the second spike comes 0.18 s after the first one (the programmed AV delay).
5. QRS: 0.16 s, wide, right after the second spike (ventricular pacing).
Interpretation
dual-chamber (AV) paced rhythm
Answer
dual-chamber (AV) 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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