Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
A patient shouts at the nurse that nobody has told them when their operation will be. What is the best first response?
AArgue back that the staff are very busy
BTell the patient to stop shouting or leave the ward
CStay calm, listen and acknowledge their frustration
DWalk away until the patient calms down by themselves
2.Nursing fundamentalsHard
A patient on a ward suddenly becomes unresponsive and is not breathing normally. What is the first action?
ACheck the blood glucose before anything else
BMeasure the blood pressure
CCall for help and start CPR
DLie the patient on the side and observe
3.Infection control & patient safetyMedium
Why are oral liquid medicines given with oral or enteral syringes rather than standard IV syringes?
AIV syringes cannot measure small volumes of oral liquid accurately
BOral syringes do not fit IV lines, preventing wrong-route errors
CThere is no safety reason; it is only tradition
DOral syringes measure intravenous doses more accurately
4.Infection control & patient safetyHard
Why can a patient with severe neutropenia have a serious infection but little redness, swelling or pus?
AChemotherapy kills the bacteria before they can multiply
BAntibiotics given with chemotherapy hide all signs of infection
CNeutropenia makes infections stay limited to the skin
DThere are too few neutrophils to produce the usual inflammatory signs
5.Prioritization & delegationMedium
A woman calls to say her husband suddenly has a drooping face and slurred speech. What should the nurse advise?
ABook an appointment with his doctor next week
BLet him lie down and see if it improves
CDrive him to the hospital yourself after he has eaten dinner
DCall emergency services now and note the time it started
6.Prioritization & delegationHard
A patient with a head injury and a leg fracture is being monitored. Which finding is the priority?
AA small graze on the elbow
BLeg pain of 6/10 despite the last dose of analgesia
CThe patient asks for something to eat
DThe Glasgow Coma Scale score falls from 15 to 12
7.Clinical nursingMedium
A patient with type 1 diabetes is vomiting and eating little. What is correct sick-day advice?
AHalve fluid intake to prevent vomiting
BStop insulin until eating normally again to avoid hypoglycaemia
CDo not stop insulin; check glucose and ketones more often
DCheck glucose once a day only
8.Clinical nursingHard
A postoperative patient on IV fluids has a sodium of 128 mmol/L and is becoming confused. Which fluid could make this worse if given in large amounts?
A5% glucose (D5W)
BHuman albumin solution
C0.9% sodium chloride
DHartmann's solution (similar to lactated Ringer's)
9.Lab values & electrolytesMedium
A patient has macrocytic anemia with numbness and tingling of the feet and poor balance. Which deficiency is most likely?
AVitamin B12
BFolate (folic acid)
CVitamin C (ascorbic acid)
DIron (low ferritin)
10.Lab values & electrolytesHard
A patient on digoxin has a calcium of 12.1 mg/dL (3.0 mmol/L) and new nausea and a slow pulse. Why is the calcium result important?
AHigh calcium only matters if the potassium is also high
BHigh calcium blocks digoxin, so the drug stops working
CHigh calcium makes the kidneys clear digoxin faster
DHigh calcium increases the risk of digoxin toxicity
11.PharmacologyMedium
Which signs suggest early lithium toxicity?
AVery high blood pressure and a severe headache
BPinpoint pupils and slow breathing
CHair loss and dark urine only
DDiarrhoea, vomiting, coarse tremor and drowsiness
12.PharmacologyHard
A patient taking metoprolol is also started on verapamil. Which adverse effect is most likely?
AHypoglycaemia and weight gain
BSevere bradycardia and heart block
CHyperkalaemia and muscle weakness
DRebound tachycardia and hypertension
13.Med-surg: cardiovascular & respiratoryMedium
A 34-year-old has hypertension that is hard to control and a low serum potassium without taking diuretics. Which cause should be considered?
APrimary hyperaldosteronism
BIron-deficiency anaemia
CEssential hypertension of ageing
DHypothyroidism
14.Med-surg: cardiovascular & respiratoryHard
Four hours after cardiac surgery, the mediastinal drain, which had been draining steadily, suddenly stops. BP falls to 84/60 mmHg, the heart rate rises and the CVP climbs. What should the nurse suspect?
AFluid overload from intravenous fluids
BCardiac tamponade from a clotted drain
CA tension pneumothorax on the left side
DNormal recovery, as the bleeding has stopped
15.Med-surg: neuro, endocrine & renalMedium
After a change in the levothyroxine dose, when is the TSH usually rechecked?
AAfter about 6–8 weeks
BAfter about 2 years of treatment
CAfter 24 hours
DAfter 3 days
16.Med-surg: neuro, endocrine & renalHard
A nurse teaches a young adult with newly diagnosed epilepsy. Which statement shows a need for further teaching?
A"I will take a shower rather than a bath."
B"I will tell my friends what to do if I have a seizure."
C"I will keep a record of any seizures I have."
D"As long as I take my tablets, I can swim alone."
17.Med-surg: GI, perioperative & oncologyMedium
What is tumour lysis syndrome?
AA slow-growing tumour that presses on the nerves
BA metabolic emergency from rapid breakdown of cancer cells
CAn allergic reaction to a chemotherapy infusion
DA skin reaction in an area recently treated with radiotherapy
18.Med-surg: GI, perioperative & oncologyHard
A surgical patient's MUST score is 3 and the wound is healing slowly. What is the most appropriate action?
ARefer to the dietitian, start a nutrition plan and monitor intake
BRestrict protein to help the kidneys
CRepeat the score in three months' time
DEncourage fasting to reduce wound exudate and the size of the dressing
19.Maternity & obstetric nursingMedium
Why are afterpains often stronger in multiparous women?
AThey produce no oxytocin after birth
BTheir uterus contracts and relaxes more irregularly
CTheir uterus is always infected
DThey have a smaller uterus than first-time mothers
20.Maternity & obstetric nursingHard
A woman in labour is receiving oxytocin. The tracing now shows recurrent late decelerations. Which action should the nurse take first?
AHelp her lie flat on her back
BIncrease the oxytocin rate to speed up the birth
CDocument the pattern and reassess in 30 minutes
DStop the oxytocin infusion
21.Pediatric nursingMedium
A newborn has a cephalohaematoma. What should the nurse monitor closely over the next days?
AUrine colour, because the swelling causes kidney damage
BBlood pressure, because the swelling causes hypertension
CJaundice, because the breakdown of the trapped blood adds to bilirubin
DHead circumference twice daily, because it signals hydrocephalus
22.Pediatric nursingHard
A 2-week-old suddenly starts vomiting bright green fluid. What should the nurse do?
ATreat it as a surgical emergency and get urgent medical review
BAdvise smaller, more frequent feeds and review the baby in a week
CChange to a lactose-free formula
DReassure the parents that this is normal reflux
23.Mental health nursingMedium
Which tool is widely used to screen for delirium at the bedside?
AThe CAGE questionnaire
BThe Confusion Assessment Method (CAM)
CThe Abnormal Involuntary Movement Scale (AIMS)
DThe CIWA-Ar
24.Mental health nursingHard
An older woman living with her son looks thin and unkempt. She says her son "looks after the money" and she is often hungry. What should the nurse do?
ATell her that she must move out of her son's home at once and stay with friends until the matter is sorted out
BTalk to her privately, document the findings and raise an adult safeguarding concern
CAsk the son in front of her whether he is stealing her money
DIgnore it, because family finances are a private matter
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 98.3 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
98.3 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A blood glucose result is 318 mg/dL. Using 1 mmol/L = 18 mg/dL for glucose, find c in mmol/L. Round to one decimal place.
318 mg/dL1 mmol/L = 18 mg/dL
c = mmol/L
27.Dosage calculationsMedium
A patient weighs 80 kg. The prescribed dose is 2 mg/kg per day, given in 3 equal doses. How many milligrams D are given per dose?
80 kg2 mg/kg/day3× per day
D = mg
28.Dosage calculationsHard
An infusion contains 40000 units of a drug in 500 mL. The prescription is 500 units per hour. At what rate R do you set the pump, in mL/h?
40000 units/500 mL500 units/h
R = mL/h
29.IV infusion ratesMedium
1000 mL was ordered over 12 hours. After 9 hours you find that 290 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 / 12 hafter 9 h: 290 mL
R = mL/h
30.IV infusion ratesHard
A bag contains 2 g of a drug in 500 mL. The order is 1 mg per minute. At what rate R do you set the pump, in mL/h?
2 g/500 mL1 mg/min
R = mL/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 20 000 units of heparin in 500 mL. The order is 15 units/kg/h for a patient who weighs 68 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL15 units/kg/h68 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 99 kg has an order for nitroglycerin at 5 mcg/min. The bag contains 25 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
25 mg/250 mL5 mcg/min99 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 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 500 mL bag was started at 12:00 and runs by pump at 120 mL/h. How many mL V are left in the bag at 15:30?
500 mL120 mL/h12:00 → 15:30
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 18/min, SpO₂ 97% on supplemental oxygen, blood pressure 96/58 mmHg, pulse 70/min, alert, temperature 38.1 °C. What is the NEWS2 total score?
RR 18SpO₂ 97%O₂SBP 96HR 70AT 38.1 °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 22/min, SpO₂ 99% on room air, blood pressure 84/50 mmHg, pulse 88/min, newly confused, temperature 34.8 °C. Which clinical risk group does the patient fall into? Click it.
RR 22SpO₂ 99%airSBP 84HR 88CT 34.8 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows PaCO₂ 80 mmHg (10.7 kPa). Use the rule that in chronic respiratory acidosis HCO₃⁻ rises by 3.5 mmol/L for every 10 mmHg that PaCO₂ is above 40, starting from HCO₃⁻ 24 mmol/L, to find the expected HCO₃⁻.
A practice gas shows a metabolic alkalosis with HCO₃⁻ 40 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 40 mmol/L
PaCO₂ = mmHg
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
1atrial fibrillation
2atrial flutter, 2:1 conduction
3supraventricular tachycardia (SVT)
4sinus tachycardia
40.ECG rhythm strip interpretationHard
This lead II strip shows a conduction problem between the atria and the ventricles. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1second-degree AV block type II
2third-degree (complete) AV block
3second-degree AV block type I (Wenckebach)
4sinus bradycardia
3Solutions
1.Nursing fundamentals
Answer: C · Stay calm, listen and acknowledge their frustration
Why this is the answer
Listening calmly and acknowledging feelings often de-escalates anger. The nurse then finds out the answer or explains what will happen next. Staff safety is maintained throughout.
Answer
C · Stay calm, listen and acknowledge their frustration
2.Nursing fundamentals
Answer: C · Call for help and start CPR
Why this is the answer
Unresponsive and not breathing normally means cardiac arrest: call for help (arrest team, defibrillator) and start chest compressions immediately.
Answer
C · Call for help and start CPR
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 · There are too few neutrophils to produce the usual inflammatory signs
Why this is the answer
Classic signs of infection come from the inflammatory response, which depends on white blood cells. With very few neutrophils, fever may be the only early sign, so it must be taken seriously.
Answer
D · There are too few neutrophils to produce the usual inflammatory signs
5.Prioritization & delegation
Answer: D · Call emergency services now and note the time it started
Why this is the answer
Stroke is time-critical. Emergency services can begin assessment on the way and take the patient to a stroke center; the time of onset guides treatment.
Answer
D · Call emergency services now and note the time it started
6.Prioritization & delegation
Answer: D · The Glasgow Coma Scale score falls from 15 to 12
Why this is the answer
A falling GCS suggests rising pressure inside the skull, which can be fatal, and needs urgent escalation. Fracture pain needs treatment too, but it does not threaten life in the same way.
Answer
D · The Glasgow Coma Scale score falls from 15 to 12
7.Clinical nursing
Answer: C · Do not stop insulin; check glucose and ketones more often
Why this is the answer
Stopping insulin in type 1 diabetes can quickly cause DKA. Patients should continue insulin, monitor glucose and ketones, drink fluids and seek help if ketones rise.
Answer
C · Do not stop insulin; check glucose and ketones more often
8.Clinical nursing
Answer: A · 5% glucose (D5W)
Why this is the answer
The glucose in 5% glucose is metabolised, leaving free water that dilutes the plasma sodium further. Postoperative patients often have raised ADH, so large volumes of hypotonic fluid can cause dangerous hyponatraemia.
Answer
A · 5% glucose (D5W)
9.Lab values & electrolytes
Answer: A · Vitamin B12
Why this is the answer
B12 and folate deficiencies both cause macrocytic anemia, but B12 deficiency also damages the spinal cord and peripheral nerves, causing numbness, tingling and poor balance. Neurological damage can become permanent if treatment is delayed.Checked against:Vitamin B12 deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2026); Vitamin B12 level - Medical Encyclopedia · MedlinePlus (NIH) (2026)
Answer
A · Vitamin B12
10.Lab values & electrolytes
Answer: D · High calcium increases the risk of digoxin toxicity
Why this is the answer
Hypercalcemia, like hypokalemia and hypomagnesemia, makes the heart more sensitive to digoxin and raises the risk of toxic arrhythmias. Nausea and bradycardia suggest toxicity, so the nurse holds the dose and reports the findings.
Answer
D · High calcium increases the risk of digoxin toxicity
11.Pharmacology
Answer: D · Diarrhoea, vomiting, coarse tremor and drowsiness
Why this is the answer
Early lithium toxicity causes GI upset, a coarse tremor, sluggishness and unsteadiness. Higher levels cause confusion, seizures and arrhythmias, so the drug is held and the level checked.
Answer
D · Diarrhoea, vomiting, coarse tremor and drowsiness
12.Pharmacology
Answer: B · Severe bradycardia and heart block
Why this is the answer
Beta blockers and non-dihydropyridine calcium channel blockers (verapamil, diltiazem) both slow heart rate and AV conduction. Together they can cause severe bradycardia, heart block and heart failure.
Answer
B · Severe bradycardia and heart block
13.Med-surg: cardiovascular & respiratory
Answer: A · Primary hyperaldosteronism
Why this is the answer
Excess aldosterone (for example from an adrenal adenoma, Conn's syndrome) causes sodium retention, hypertension and potassium loss. Young age, resistant hypertension and unexplained hypokalaemia suggest a secondary cause and need investigation.
Answer
A · Primary hyperaldosteronism
14.Med-surg: cardiovascular & respiratory
Answer: B · Cardiac tamponade from a clotted drain
Why this is the answer
A sudden stop in drainage with falling blood pressure, tachycardia and rising venous pressure suggests blood is collecting around the heart because the drain is blocked. Tamponade after cardiac surgery is an emergency: the surgeon is called at once and the chest may need to be reopened.
Answer
B · Cardiac tamponade from a clotted drain
15.Med-surg: neuro, endocrine & renal
Answer: A · After about 6–8 weeks
Why this is the answer
Levothyroxine has a half-life of about a week, so it takes several weeks to reach a new steady state. TSH is usually rechecked about 6–8 weeks after a dose change.
Answer
A · After about 6–8 weeks
16.Med-surg: neuro, endocrine & renal
Answer: D · "As long as I take my tablets, I can swim alone."
Why this is the answer
People with epilepsy should never swim alone, even if their seizures are well controlled. Showers are safer than baths. Telling friends about first aid and keeping a seizure diary are good practice.
Answer
D · "As long as I take my tablets, I can swim alone."
17.Med-surg: GI, perioperative & oncology
Answer: B · A metabolic emergency from rapid breakdown of cancer cells
Why this is the answer
Rapid tumour cell death, usually after starting treatment for fast-growing cancers such as acute leukaemia or high-grade lymphoma, releases potassium, phosphate and nucleic acids (converted to uric acid). This can cause AKI and arrhythmias.
Answer
B · A metabolic emergency from rapid breakdown of cancer cells
18.Med-surg: GI, perioperative & oncology
Answer: A · Refer to the dietitian, start a nutrition plan and monitor intake
Why this is the answer
A MUST score of 2 or more indicates high risk of malnutrition. Poor nutrition delays healing, so the nurse refers to the dietitian, starts a care plan with food charts and supplements as advised, and rescreens regularly.
Answer
A · Refer to the dietitian, start a nutrition plan and monitor intake
19.Maternity & obstetric nursing
Answer: B · Their uterus contracts and relaxes more irregularly
Why this is the answer
In multiparas, and after overdistension such as twins, the uterus relaxes and contracts intermittently, causing stronger afterpains. Breastfeeding increases them through oxytocin.
Answer
B · Their uterus contracts and relaxes more irregularly
20.Maternity & obstetric nursing
Answer: D · Stop the oxytocin infusion
Why this is the answer
Stopping the oxytocin reduces contraction-related loss of placental flow. Other steps follow at once: a lateral position, an IV fluid bolus as ordered, checking maternal blood pressure and notifying the provider. Waiting or lying supine makes the hypoxia worse.
Answer
D · Stop the oxytocin infusion
21.Pediatric nursing
Answer: C · Jaundice, because the breakdown of the trapped blood adds to bilirubin
Why this is the answer
A cephalohaematoma is a collection of blood under the periosteum. As the red cells break down, bilirubin rises, so these babies have a higher risk of jaundice. The swelling itself usually resolves over weeks without treatment.
Answer
C · Jaundice, because the breakdown of the trapped blood adds to bilirubin
22.Pediatric nursing
Answer: A · Treat it as a surgical emergency and get urgent medical review
Why this is the answer
Bilious vomiting in a newborn suggests bowel obstruction, such as malrotation with volvulus, which can cut off the blood supply to the gut within hours. It needs immediate surgical assessment.
Answer
A · Treat it as a surgical emergency and get urgent medical review
23.Mental health nursing
Answer: B · The Confusion Assessment Method (CAM)
Why this is the answer
The CAM checks for acute onset and fluctuating course, inattention, and either disorganised thinking or an altered level of consciousness. Other tools, such as the 4AT, are also used.
Answer
B · The Confusion Assessment Method (CAM)
24.Mental health nursing
Answer: B · Talk to her privately, document the findings and raise an adult safeguarding concern
Why this is the answer
Signs of financial abuse and neglect require a private conversation, careful documentation and reporting through safeguarding procedures. Confrontation could increase the risk to her.
Answer
B · Talk to her privately, document the findings and raise an adult safeguarding concern
25.Nursing math & unit conversions
Answer: T = 36.8 °C
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.
Subtract 32
98.3 − 32 = 66.3
Multiply by 5/9
T = 66.3·5/9 = 36.83 ≈ 36.8 °C
Answer
T = 36.8 °C
26.Nursing math & unit conversions
Answer: c = 17.7 mmol/L
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
c = 318/18 = 17.67 ≈ 17.7 mmol/L
Answer
c = 17.7 mmol/L
27.Dosage calculations
Answer: D = 53.33 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
2·80 = 160 mg
Per dose
D = 160/3 = 53.33 mg
Answer
D = 53.33 mg
28.Dosage calculations
Answer: R = 6.25 mL/h
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.
Concentration
40000/500 = 80 units/mL
Pump rate
R = 500/80 = 6.25 mL/h
Answer
R = 6.25 mL/h
29.IV infusion rates
Answer: R = 96.67 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
1000/12 = 83.33 mL/h
New rate
R = 290/3 = 96.67 mL/h
Answer
R = 96.67 mL/h
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
30.IV infusion rates
Answer: R = 15 mL/h
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
Concentration
2000 mg/500 mL = 4 mg/mL
Dose per hour
1·60 = 60 mg/h
Pump rate
R = 60/4 = 15 mL/h
Answer
R = 15 mL/h
31.Pediatric & critical-care dosing
Answer: R = 25.5 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
15·68 = 1 020 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1020/40 = 25.5 mL/h
Answer
R = 25.5 mL/h
32.Pediatric & critical-care dosing
Answer: R = 3 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
25 000/250 = 100 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
5·60 = 300 mcg/h
Pump rate
R = 300/100 = 3 mL/h
Answer
R = 3 mL/h
33.IV fluids & fluid balance
Answer: B = 250 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: 75·12 = 900 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1250 mL
Total output
500 + 350 + 150 = 1000 mL
Balance
B = 1250 − 1000 = 250 mL
Answer
B = 250 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: V = 80 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
12:00 → 15:30 = 3.5 h
Volume infused
120·3.5 = 420 mL
Volume left
V = 500 − 420 = 80 mL
Answer
V = 80 mL
35.Clinical assessment scores
Answer: NEWS2 = 5
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 18/min → 0
SpO₂ 97% → 0
on oxygen → 2
SBP 96 mmHg → 2
HR 70/min → 0
alert (A) → 0
T 38.1 °C → 1
Add
NEWS2 = 0 + 0 + 2 + 2 + 0 + 0 + 1 = 5
Answer
NEWS2 = 5
36.Clinical assessment scores
Answer: high
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 22/min → 2
SpO₂ 99% → 0
on air → 0
SBP 84 mmHg → 3
HR 88/min → 0
newly confused (C) → 3
T 34.8 °C → 3
Total and red scores
NEWS2 = 2 + 0 + 0 + 3 + 0 + 3 + 3 = 11
At least one parameter scores 3.
Risk group
high
Answer
high
A total of 5 or more calls for an urgent clinical response.
37.Arterial blood gas interpretation
Answer: HCO₃⁻ = 38 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
|80 − 40| = 40 mmHg → 4 × 10 mmHg
Expected HCO₃⁻
HCO₃⁻ = 24 + 3.5·4 = 38 mmol/L
Answer
HCO₃⁻ = 38 mmol/L
38.Arterial blood gas interpretation
Answer: PaCO₂ = 49 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
0.7·40 + 21 = 49 mmHg
Answer
PaCO₂ = 49 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: supraventricular tachycardia (SVT)
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC. Narrow-complex tachycardia and pauses: supraventricular tachycardia (SVT) is a regular tachycardia at about 150–250/min with narrow QRS complexes; the P waves are usually not visible because they are hidden in the QRS complex or the T wave. Sinus tachycardia in an adult at rest is usually below about 150/min and has a visible P wave before every QRS; atrial flutter with 2:1 conduction often runs at about 150/min and shows sawtooth waves. In sinus arrest the sinus node stops firing for a moment: a pause with no P wave and no QRS whose length is not a whole number of P–P cycles (a pause of exactly two or three cycles points to sinus exit block instead).
Five steps
1. Rate: R–R = 9 small boxes, 1500 ÷ 9 ≈ 167 per minute.
2. Rhythm: regular, every R–R is 0.36 s.
3. P waves: none visible; at this rate they are hidden in the QRS complexes or the T waves.
4. PR interval: not measurable.
5. QRS: 0.06 s, narrow (below 0.12 s), so the rhythm starts above the ventricles.
Interpretation
supraventricular tachycardia (SVT)
Answer
supraventricular tachycardia (SVT)
40.ECG rhythm strip interpretation
Answer: second-degree AV block type II
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Five steps
1. Rate: 5 QRS complexes in 6 s, × 10 = 50 per minute.
2. Rhythm: the P waves are regular; R–R is regular except for a long pause where a QRS is missing.
3. P waves: upright and regular (P–P 0.92 s, 65 per minute); one P in every 4 is not followed by a QRS.
4. PR interval: constant at 0.16 s in the conducted beats.
5. QRS: 0.12 s, wide (0.12 s or more).
Interpretation
second-degree AV block type II
Answer
second-degree AV block type II
Type II and third-degree blocks are the ones that can suddenly progress, so textbooks rank them as more serious than type I.
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