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
If hair needs to be removed before surgery, what is recommended?
AHair removal cream applied in theatre
BPlucking the hairs with tweezers
CElectric clippers on the day of surgery
DShaving with a razor the night before
2.Nursing fundamentalsHard
An older woman with severe arthritis has normal bladder control but wets herself because she cannot reach the toilet in time. Which type of incontinence is this?
AOverflow incontinence
BStress incontinence
CFunctional incontinence
DUrge incontinence
3.Infection control & patient safetyMedium
Why are oral liquid medicines given with oral or enteral syringes rather than standard IV syringes?
AThere is no safety reason; it is only tradition
BOral syringes do not fit IV lines, preventing wrong-route errors
COral syringes measure intravenous doses more accurately
DIV syringes cannot measure small volumes of oral liquid accurately
4.Infection control & patient safetyHard
Several patients on a ward develop vomiting and diarrhea within two days, and a norovirus outbreak is suspected. What should the nurse do first?
AAsk visitors to bring in bottled water for all patients
BWait for all the stool results to come back before taking any action
CMove the affected patients to different wards so that fewer people are exposed
DNotify the infection prevention team and place affected patients on contact precautions
5.Prioritization & delegationMedium
Which task should the nurse delegate to a nursing assistant for a patient on fall precautions?
ADeciding whether the bed alarm is still needed
BTeaching the family how to prevent falls at home
CHelping the patient to the toilet every 2 hours as planned
DAssessing and recording the patient’s fall risk score each morning
6.Prioritization & delegationHard
A patient’s serum potassium is 6.1 mEq/L. Which of the patient’s medications should the nurse question first?
ASpironolactone
BHydrochlorothiazide
CFurosemide
DOmeprazole
7.Clinical nursingMedium
A patient with chronic kidney disease should usually limit which of these in their diet?
ACarbohydrates completely
BVitamin C and fibre
CPotassium and phosphate
DWater-soluble vitamins only
8.Clinical nursingHard
A patient with acute pancreatitis is in severe epigastric pain radiating to the back. Which nursing care is most important?
ARestricting all fluids
BAdequate pain relief, IV fluids and close fluid balance monitoring
CStrict bed rest without observations
DA large fatty meal to stimulate the pancreas
9.Lab values & electrolytesMedium
A patient with suspected pulmonary TB needs sputum samples for acid-fast bacilli. Which instruction is correct?
AGive several samples of nasal mucus blown into a tissue
BGive several deep-cough samples, often first thing in the morning
CGive one sample after brushing with mouthwash so it is clean
DGive one sample of saliva collected from the mouth at any time of day
10.Lab values & electrolytesHard
A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?
AA loop diuretic to remove the extra sodium quickly
BRapid infusion of 3% saline to raise the volume
CStrict fluid restriction to below 800 mL a day
DGradual replacement of free water over many hours
11.PharmacologyMedium
A patient starting niacin (nicotinic acid) complains of flushing and warmth after doses. Which advice may reduce this?
ATake the niacin with a hot drink so that it dissolves and acts faster
BDouble the dose to build tolerance faster
CTake it on an empty stomach in a hot bath
DTake aspirin 30 minutes before the niacin, if the prescriber agrees
12.PharmacologyHard
A patient took a doxycycline tablet with a sip of water just before lying down. Now swallowing is very painful. What is the most likely cause?
AGastric ulcer caused by doxycycline
BPill-induced oesophagitis
COral candidiasis from the antibiotic
DAn allergic reaction to the tablet coating
13.Med-surg: cardiovascular & respiratoryMedium
A patient has pneumonia in the right lung only. In which side-lying position will oxygenation usually be best?
AProne with the head down
BLying on the left side, with the healthy lung down
CLying on the right side, with the affected lung down
DFlat on the back with no pillows
14.Med-surg: cardiovascular & respiratoryHard
A patient with asthma needs their reliever every three hours and their peak flow is falling well below their personal best. What does their action plan most likely advise?
AStop the preventer inhaler for a few days to rest the lungs
BWait two weeks to see whether it improves without any change
CDo extra exercise to open the airways
DFollow the worsening-asthma steps and get a same-day review
15.Med-surg: neuro, endocrine & renalMedium
A patient taking dapagliflozin (an SGLT2 inhibitor) is vomiting, with blood ketones of 4.5 mmol/L but a glucose of only 11 mmol/L. What should be suspected?
AEuglycaemic diabetic ketoacidosis
BA normal side effect needing no action
CHypoglycaemia caused by the vomiting
DHyperosmolar hyperglycaemic state
16.Med-surg: neuro, endocrine & renalHard
Which medication timing issue is important for patients on haemodialysis?
ADialysis does not remove any medicines
BAll medicines must be given just before the session
CDialysable drugs may need to be given after the session
DNo medicines can be taken on dialysis days
17.Med-surg: GI, perioperative & oncologyMedium
For which stoma can colostomy irrigation be considered?
AAn ileal conduit draining urine
BAny stoma that has liquid or very loose output
CA new ileostomy in the first week
DAn established descending or sigmoid colostomy
18.Med-surg: GI, perioperative & oncologyHard
On day 3 after laparoscopic cholecystectomy, a patient has abdominal pain, fever and mild jaundice, and green fluid is draining from the drain. What is most likely?
AUrinary retention
BA wound haematoma
CA bile leak
DNormal post-operative drainage
19.Maternity & obstetric nursingMedium
Where universal screening for group B streptococcus is used, when is the vaginal–rectal swab usually taken?
AAt about 36 to 37 weeks
BAt the first antenatal visit
CAt about 20 weeks
DAfter the membranes rupture in labour
20.Maternity & obstetric nursingHard
A woman attempting a vaginal birth after a previous caesarean suddenly has severe abdominal pain, the fetal heart rate drops sharply and the presenting part can no longer be felt. What is most likely?
ANormal progress into the second stage
BUterine rupture
CPlacenta praevia
DEarly decelerations from head compression
21.Pediatric nursingMedium
In a large ventricular septal defect, in which direction does blood mainly flow through the defect?
AThere is no flow at all, because the pressures in both ventricles are always equal
BFrom left to right, increasing blood flow to the lungs
CFrom right to left, causing cyanosis from birth
DFrom the aorta into the pulmonary veins
22.Pediatric nursingHard
The nurse has taught the parents of a child with epilepsy. Which statement shows a need for further teaching?
A"I'll time the seizure and give the rescue medicine if it lasts too long."
B"I'll move hard objects away and put something soft under his head."
C"When the jerking stops, I'll turn him onto his side."
D"I'll put a spoon in his mouth so he doesn't bite or swallow his tongue."
23.Mental health nursingMedium
A patient on lamotrigine for bipolar disorder develops a new rash. What should the nurse do?
AIgnore it, because rashes are always harmless
BReport it promptly, because it may be the start of a serious skin reaction
CDouble the dose
DApply a moisturiser, and continue the drug as normal because rashes are common
24.Mental health nursingHard
A colleague suggests putting a loud but non-violent patient in seclusion "because he's annoying everyone". What is the correct response?
AIt would be inappropriate, because seclusion is only a last resort for serious risk of harm
BIt is acceptable as long as the patient agrees afterwards
CIt is acceptable as long as the seclusion lasts for less than an hour
DIt is acceptable, because it will make the ward quieter and safer for the other patients
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 36.6 °C. Convert it to degrees Fahrenheit T with °F = °C × 9/5 + 32. Round to one decimal place.
36.6 °C
T = °F
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 1 tsp of cough syrup, ¾ cup of tea, 1½ fl oz of juice. Using the equivalents given, find the total oral intake V in mL.
1 tsp = 5 mL1 cup = 8 fl oz = 240 mL1 fl oz = 30 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 80 kg and is prescribed 2 mg/kg as a single dose. Find the dose D in mg.
80 kg2 mg/kg
D = mg
28.Dosage calculationsHard
A patient is 183 cm tall and weighs 50 kg. The prescription is 50 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
183 cm50 kg50 mg/m²
D = mg
29.IV infusion ratesMedium
Infuse 500 mL over 2 hours with a giving set of 10 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL2 h10 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 200 mg of a drug in 100 mL and runs at 10 mL/h. How many milligrams per hour D does the patient receive?
200 mg/100 mL10 mL/h
D = mg/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 100 units of regular insulin in 50 mL runs at 6 mL/h. How many units per hour D does the patient receive?
100 units/50 mL6 mL/h
D = units/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 100 kg has an order for norepinephrine at 4 mcg/min. The bag contains 4 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
4 mg/250 mL4 mcg/min100 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 500 mL bag was started at 07:45 and runs by pump at 150 mL/h. How many mL V are left in the bag at 10:45?
500 mL150 mL/h07:45 → 10:45
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: no; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: yes; gait: impaired; mental status: knows own limits. Find the Morse total MFS.
0–125
MFS =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 21/min, SpO₂ 97% on room air, blood pressure 112/68 mmHg, pulse 70/min, alert, temperature 39.6 °C. Which clinical risk group does the patient fall into? Click it.
RR 21SpO₂ 97%airSBP 112HR 70AT 39.6 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.19, PaCO₂ 65 mmHg (8.7 kPa) and HCO₃⁻ 24 mmol/L. The primary disorder is respiratory acidosis. How far is it compensated? Click your answer.
pH 7.19PaCO₂ 65 mmHg (8.7 kPa)HCO₃⁻ 24 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.15, PaCO₂ 50 mmHg (6.7 kPa), HCO₃⁻ 17 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.15PaCO₂ 50 mmHg (6.7 kPa)HCO₃⁻ 17 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 arrhythmia
2atrial fibrillation
3normal sinus rhythm
4ventricular bigeminy
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
1ventricular paced rhythm
2paced rhythm, failure to capture
3idioventricular rhythm
4third-degree (complete) AV block
3Solutions
1.Nursing fundamentals
Answer: C · Electric clippers on the day of surgery
Why this is the answer
Razors cause small skin cuts that increase surgical site infection. If needed, hair is removed with electric clippers close to the time of surgery.
Answer
C · Electric clippers on the day of surgery
2.Nursing fundamentals
Answer: C · Functional incontinence
Why this is the answer
Functional incontinence is caused by problems outside the urinary tract, such as poor mobility or confusion. A commode near the bed, easy clothing and regular toileting help.
Answer
C · Functional incontinence
3.Infection control & patient safety
Answer: B · Oral syringes do not fit IV lines, preventing wrong-route errors
Why this is the answer
Oral and enteral syringes have connectors that do not fit IV ports, so an oral liquid cannot be injected into a vein by mistake. Wrong-route errors with oral liquids have been fatal.
Answer
B · Oral syringes do not fit IV lines, preventing wrong-route errors
4.Infection control & patient safety
Answer: D · Notify the infection prevention team and place affected patients on contact precautions
Why this is the answer
Early reporting lets infection prevention organize testing, cohorting, closing of the ward if needed, cleaning with suitable agents and soap-and-water hand hygiene. Moving patients around can spread the outbreak.
Answer
D · Notify the infection prevention team and place affected patients on contact precautions
5.Prioritization & delegation
Answer: C · Helping the patient to the toilet every 2 hours as planned
Why this is the answer
A scheduled toileting round is a routine task that follows the care plan. Scoring fall risk, deciding on interventions and teaching need nursing judgement.
Answer
C · Helping the patient to the toilet every 2 hours as planned
6.Prioritization & delegation
Answer: A · Spironolactone
Why this is the answer
Spironolactone is a potassium-sparing diuretic and can raise potassium further. Furosemide and thiazides tend to lower potassium, and omeprazole does not usually affect it.
Answer
A · Spironolactone
7.Clinical nursing
Answer: C · Potassium and phosphate
Why this is the answer
Failing kidneys excrete potassium and phosphate poorly, so dietary limits are often needed, along with salt and sometimes fluid and protein limits.
Answer
C · Potassium and phosphate
8.Clinical nursing
Answer: B · Adequate pain relief, IV fluids and close fluid balance monitoring
Why this is the answer
Acute pancreatitis can cause large fluid losses and organ failure. Care focuses on fluid resuscitation, analgesia, monitoring urine output, glucose and early nutrition when possible.
Answer
B · Adequate pain relief, IV fluids and close fluid balance monitoring
9.Lab values & electrolytes
Answer: B · Give several deep-cough samples, often first thing in the morning
Why this is the answer
Usually a series of three sputum samples is collected, at least one in the early morning, when secretions have pooled overnight. The patient rinses with water (not mouthwash), takes deep breaths and coughs deeply to bring up sputum, not saliva. Airborne precautions are used.
Answer
B · Give several deep-cough samples, often first thing in the morning
10.Lab values & electrolytes
Answer: D · Gradual replacement of free water over many hours
Why this is the answer
Older adults have a reduced sense of thirst and easily develop hypernatremia from water loss. Free water is replaced gradually, because lowering sodium too quickly can cause cerebral edema. Hypertonic saline and fluid restriction would make it worse.
Answer
D · Gradual replacement of free water over many hours
11.Pharmacology
Answer: D · Take aspirin 30 minutes before the niacin, if the prescriber agrees
Why this is the answer
Niacin causes prostaglandin-mediated vasodilation and flushing. Aspirin beforehand, taking it with food and avoiding hot drinks and alcohol reduce this effect.
Answer
D · Take aspirin 30 minutes before the niacin, if the prescriber agrees
12.Pharmacology
Answer: B · Pill-induced oesophagitis
Why this is the answer
Doxycycline can cause oesophageal ulceration if it stays in the oesophagus. It is taken with a full glass of water while upright, and the patient stays upright for at least 30 minutes.
Answer
B · Pill-induced oesophagitis
13.Med-surg: cardiovascular & respiratory
Answer: B · Lying on the left side, with the healthy lung down
Why this is the answer
Blood flow goes preferentially to the dependent lung. Placing the healthy lung down matches more blood to the well-ventilated lung, improving oxygenation ("good lung down"). Exceptions include a lung abscess or bleeding, when the affected lung is placed down to protect the healthy one.
Answer
B · Lying on the left side, with the healthy lung down
14.Med-surg: cardiovascular & respiratory
Answer: D · Follow the worsening-asthma steps and get a same-day review
Why this is the answer
Personal asthma action plans set steps based on symptoms and peak flow compared with the personal best. Increasing reliever need and a falling peak flow mean worsening asthma: treatment is increased as the plan says (sometimes with oral steroids) and urgent review is sought. Severe signs need emergency care.
Answer
D · Follow the worsening-asthma steps and get a same-day review
15.Med-surg: neuro, endocrine & renal
Answer: A · Euglycaemic diabetic ketoacidosis
Why this is the answer
SGLT2 inhibitors lower glucose by increasing urinary glucose loss, so DKA can occur with only moderately raised glucose. Ketones should be checked in any unwell patient on these drugs, and the drug is stopped during acute illness (sick-day rules).
Answer
A · Euglycaemic diabetic ketoacidosis
16.Med-surg: neuro, endocrine & renal
Answer: C · Dialysable drugs may need to be given after the session
Why this is the answer
Drugs that are dialysable (for example some antibiotics) may be given after the session so they are not removed. Antihypertensives are often withheld before dialysis to avoid hypotension. The prescriber and pharmacist set the timing.
Answer
C · Dialysable drugs may need to be given after the session
17.Med-surg: GI, perioperative & oncology
Answer: D · An established descending or sigmoid colostomy
Why this is the answer
Irrigation instils water into a sigmoid or descending colostomy to empty the bowel at set times. It is not used for ileostomies or urostomies and needs specialist teaching.
Answer
D · An established descending or sigmoid colostomy
18.Med-surg: GI, perioperative & oncology
Answer: C · A bile leak
Why this is the answer
Bile leakage from the cystic duct or a duct injury causes pain, fever and sometimes jaundice, with bile in the drain. It needs urgent surgical review and often ERCP and stenting.
Answer
C · A bile leak
19.Maternity & obstetric nursing
Answer: A · At about 36 to 37 weeks
Why this is the answer
Colonisation can come and go, so the swab is taken late in pregnancy, close to birth. A positive result leads to intrapartum antibiotics to protect the newborn. Some countries use a risk-based approach instead.
Answer
A · At about 36 to 37 weeks
20.Maternity & obstetric nursing
Answer: B · Uterine rupture
Why this is the answer
Sudden pain, fetal bradycardia and loss of station are classic signs of uterine rupture, a rare but life-threatening emergency that requires immediate surgery.
Answer
B · Uterine rupture
21.Pediatric nursing
Answer: B · From left to right, increasing blood flow to the lungs
Why this is the answer
Left ventricular pressure is higher, so blood flows from left to right, overloading the lungs and right heart. This causes increased pulmonary blood flow and can lead to heart failure in infancy.
Answer
B · From left to right, increasing blood flow to the lungs
22.Pediatric nursing
Answer: D · "I'll put a spoon in his mouth so he doesn't bite or swallow his tongue."
Why this is the answer
Putting objects in the mouth can break teeth, injure the mouth or block the airway; the tongue cannot be swallowed. Timing the seizure, protecting from injury and placing the child on the side afterwards are correct.
Answer
D · "I'll put a spoon in his mouth so he doesn't bite or swallow his tongue."
23.Mental health nursing
Answer: B · Report it promptly, because it may be the start of a serious skin reaction
Why this is the answer
Lamotrigine can cause Stevens–Johnson syndrome, especially early in treatment or if the dose is increased too quickly. Any rash needs prompt medical review.
Answer
B · Report it promptly, because it may be the start of a serious skin reaction
24.Mental health nursing
Answer: A · It would be inappropriate, because seclusion is only a last resort for serious risk of harm
Why this is the answer
Seclusion is a restrictive intervention used only to contain severe behaviour likely to cause harm to others, as a last resort, for the shortest time. Using it for convenience or punishment breaches patients' rights.
Answer
A · It would be inappropriate, because seclusion is only a last resort for serious risk of harm
25.Nursing math & unit conversions
Answer: T = 97.9 °F
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Multiply by 9/5
36.6·9/5 = 65.88
Add 32
T = 65.88 + 32 = 97.88 ≈ 97.9 °F
Answer
T = 97.9 °F
26.Nursing math & unit conversions
Answer: V = 230 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
1 tsp = 1·5 = 5 mL
¾ cup = 0.75·240 = 180 mL
1½ fl oz = 1.5·30 = 45 mL
Add
V = 5 + 180 + 45 = 230 mL
Answer
V = 230 mL
27.Dosage calculations
Answer: D = 160 mg
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Dose
2·80 = 160 mg
Answer
D = 160 mg
28.Dosage calculations
Answer: D = 79.71 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).
Body surface area
BSA = √(183·50/3600) = √2.542 = 1.594 m²
Dose
D = 50·1.594 = 79.71 mg
Answer
D = 79.71 mg
29.IV infusion rates
Answer: R = 42 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.
Time in minutes
2·60 = 120 min
Drip rate
R = 500·10/120 = 41.67 ≈ 42 gtt/min
Answer
R = 42 gtt/min
At the bedside you round to the nearest whole drop: 42 gtt/min.
30.IV infusion rates
Answer: D = 20 mg/h
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Concentration
200/100 = 2 mg/mL
Dose rate
D = 2·10 = 20 mg/h
Answer
D = 20 mg/h
31.Pediatric & critical-care dosing
Answer: D = 12 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
100/50 = 2 units/mL
Units per hour
D = 6·2 = 12 units/h
Answer
D = 12 units/h
32.Pediatric & critical-care dosing
Answer: R = 15 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
4 000/250 = 16 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
4·60 = 240 mcg/h
Pump rate
R = 240/16 = 15 mL/h
Answer
R = 15 mL/h
33.IV fluids & fluid balance
Answer: B = −55 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: 150 + 240 + 120 = 510 mL
IV infusion: 60·8 = 480 mL
IV antibiotic: 2·100 = 200 mL
total intake = 1190 mL
Total output
325 + 500 + 350 + 70 = 1245 mL
Balance
B = 1190 − 1245 = −55 mL
Answer
B = −55 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: V = 50 mL
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.
Elapsed time
07:45 → 10:45 = 3 h
Volume infused
150·3 = 450 mL
Volume left
V = 500 − 450 = 50 mL
Answer
V = 50 mL
35.Clinical assessment scores
Answer: MFS = 80
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: no → 0
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: yes → 20
gait: impaired → 20
mental status: knows own limits → 0
Add
Morse total = 25 + 0 + 15 + 20 + 20 + 0 = 80
Answer
MFS = 80
36.Clinical assessment scores
Answer: low
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 21/min → 2
SpO₂ 97% → 0
on air → 0
SBP 112 mmHg → 0
HR 70/min → 0
alert (A) → 0
T 39.6 °C → 2
Total and red scores
NEWS2 = 2 + 0 + 0 + 0 + 0 + 0 + 2 = 4
No parameter scores 3.
Risk group
low
Answer
low
37.Arterial blood gas interpretation
Answer: uncompensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.19: acidaemia (below 7.35)
PaCO₂ 65 mmHg: high (35–45)
HCO₃⁻ 24 mmol/L: normal (22–26)
Compensation
uncompensated
Answer
uncompensated
38.Arterial blood gas interpretation
Answer: added respiratory acidosis
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
1.5·17 + 8 = 33.5 → 31.5–35.5 mmHg
Compare
measured: 50 mmHg → added respiratory acidosis
Answer
added respiratory acidosis
39.ECG rhythm strip interpretation
Answer: ventricular bigeminy
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: 7 QRS complexes in 6 s, × 10 = 70 per minute.
2. Rhythm: regularly irregular, a short and a long R–R alternate (0.52 s and 1.16 s).
3. P waves: upright before every narrow QRS; none before the early wide beats.
4. PR interval: 0.16 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s in the sinus beats; the early beats are wide (0.14 s) and bizarre, with the T wave pointing the other way.
Interpretation
ventricular bigeminy
Answer
ventricular bigeminy
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 = 24 small boxes, 1500 ÷ 24 ≈ 63 per minute.
2. Rhythm: regular, every R–R is 0.96 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.