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
Which stool sample is suitable for Clostridioides difficile testing?
AA dry smear of stool on a tissue
BA stool sample mixed with urine
CA hard, formed stool collected first thing in the morning
DA loose stool that takes the shape of the container
2.Nursing fundamentalsHard
An elderly patient on intravenous fluids becomes breathless, with crackles in the lungs and swollen ankles. What is the most likely problem?
ADehydration
BHypoglycaemia
CNormal response to IV fluids
DFluid overload
3.Infection control & patient safetyMedium
A nurse pours sterile saline into a bowl on a sterile field. Which technique is correct?
ARest the lip of the bottle on the edge of the bowl so that the saline does not splash
BPour from below the level of the field to reduce splashing
CReach across the field to fill the bowl at the far side
DHold the bottle with the label in the palm and pour without touching the bowl
4.Infection control & patient safetyHard
During a power cut in a US hospital, a ventilator must stay powered. Where should it be plugged in?
AInto an extension cord from the corridor
BInto the outlet that is closest to the bed, whatever its color
CInto a red outlet connected to the emergency generator
DInto any white outlet in the room
5.Prioritization & delegationMedium
Which SBAR recommendation is the clearest?
A“I will keep watching him and call again tomorrow.”
B“He seems a bit off tonight, so maybe you could come up and do something about it.”
C“I just wanted to let you know about him.”
D“I would like you to see him within 15 minutes and consider a fluid bolus.”
6.Prioritization & delegationHard
Four stable patients need routine morning care. To reduce the spread of infection, which patient should the nurse visit first?
AA patient with neutropenia after chemotherapy
BA patient with influenza on droplet precautions
CA patient with an MRSA wound infection
DA patient with C. difficile diarrhea
7.Clinical nursingMedium
A patient with type 2 diabetes is acutely unwell, very dehydrated and has a blood glucose of 40 mmol/L without significant ketones. What is the most likely diagnosis?
ADiabetes insipidus
BHypoglycaemia
CHyperosmolar hyperglycaemic state
DDiabetic ketoacidosis with dehydration
8.Clinical nursingHard
A patient has sudden, severe "tearing" chest pain going through to the back and a large difference in blood pressure between the arms. What should be suspected?
APericarditis
BAortic dissection
CStable angina
DGastro-oesophageal reflux
9.Lab values & electrolytesMedium
A patient with joint aches has a positive antinuclear antibody (ANA) test. Which statement is correct?
AA positive ANA proves the patient has rheumatoid arthritis
BA positive ANA means the patient has a viral infection
CA positive ANA rules out all other autoimmune diseases
DA positive ANA supports lupus but does not diagnose it alone
10.Lab values & electrolytesHard
Which cerebrospinal fluid (CSF) pattern most strongly suggests bacterial meningitis?
AClear fluid, normal glucose, mildly raised protein, lymphocytes
BClear fluid, high glucose, low protein, many red cells
CClear fluid, normal glucose, normal protein, no white cells
DCloudy fluid, low glucose, high protein, many neutrophils
11.PharmacologyMedium
An IV site is cool, swollen and pale, and the infusion is running slowly. What should the nurse do?
AFlush the cannula forcefully with saline
BStop the infusion, remove the cannula and elevate the limb
CApply a tight bandage over the site
DIncrease the infusion rate to push through and clear the blockage
12.PharmacologyHard
On admission, a patient's home medicine list includes warfarin for atrial fibrillation, but warfarin is not on the admission orders. What should the nurse do?
AAssume the omission is intended and do nothing
BClarify the omission with the prescriber (medication reconciliation)
CTell the patient to stop warfarin permanently
DGive the patient's own warfarin brought from home without an order
13.Med-surg: cardiovascular & respiratoryMedium
Which laboratory test is used to adjust an unfractionated heparin infusion?
AaPTT (or anti-Xa level)
BINR (international normalised ratio)
CSerum fibrinogen level
DD-dimer level
14.Med-surg: cardiovascular & respiratoryHard
A healthcare assistant (unlicensed assistive personnel) reports four observations. Which one needs the nurse's attention first?
AA patient after a PCI asking for a cup of tea
BA patient with COPD whose SpO₂ is 90% on 1 L/min, which is usual for him
CA patient with heart failure who is newly confused, with SpO₂ 89%
DA patient with a DVT whose leg is less swollen today
15.Med-surg: neuro, endocrine & renalMedium
Several hours after a carotid endarterectomy, which finding needs the most urgent action?
AA blood pressure slightly above the baseline
BAn expanding neck swelling with noisy breathing
CA small amount of dried blood on the dressing
DMild pain at the incision site
16.Med-surg: neuro, endocrine & renalHard
The nurse has four patients. Which one needs to be seen first?
AA patient with hypothyroidism asking when to take levothyroxine
BA patient with stable CKD waiting for a renal diet review
CA patient with Parkinson's disease whose next dose is due in two hours
DA patient on insulin for DKA whose potassium is now 2.9 mmol/L
17.Med-surg: GI, perioperative & oncologyMedium
Why is it important to prevent perioperative hypothermia?
AIt increases bleeding, wound infection and heart complications
BIt lowers the risk of pain after surgery
CIt reduces the amount of anaesthetic needed, which is unsafe
DIt makes patients wake up from the anaesthetic too quickly
18.Med-surg: GI, perioperative & oncologyHard
A patient with three fractured ribs is taking shallow breaths because of pain. Why is effective analgesia a priority?
AShallow breathing can lead to atelectasis and pneumonia
BPain relief is only needed for the patient's comfort
CGood analgesia makes rib fractures heal fully within a few days
DRib pain always means the heart is damaged
19.Maternity & obstetric nursingMedium
Lochia with a foul odour on day 3 after birth most likely indicates:
AA uterine infection (endometritis)
BDehydration
CNormal lochia
DA full bladder pressing on the uterus
20.Maternity & obstetric nursingHard
After the membranes rupture, the nurse sees the umbilical cord protruding from the vagina. What is the first action?
ACall for help and lift the presenting part off the cord with a gloved hand
BCover the cord with a dry towel, keep her lying flat and wait for the doctor
CAsk the woman to push with the next contraction
DGently push the cord back into the vagina
21.Pediatric nursingMedium
A child's tonic–clonic seizure has stopped and she is drowsy. What should the nurse do?
AWake her fully every few minutes and ask her to stand up and walk around
BPlace her in the recovery position and monitor airway and breathing
CGive her a drink straight away to prevent dehydration
DLeave her alone in a dark room to sleep it off
22.Pediatric nursingHard
A 7-year-old has a fever, joint pain moving from joint to joint and a new heart murmur, three weeks after a sore throat. What should the nurse suspect?
AKawasaki disease
BGrowing pains
CJuvenile idiopathic arthritis with no link to the sore throat
DAcute rheumatic fever
23.Mental health nursingMedium
A patient who has taken lithium for 3 years reports tiredness, weight gain, feeling cold and constipation. Which problem should be checked?
AHyperthyroidism
BAgranulocytosis
CSerotonin syndrome
DHypothyroidism
24.Mental health nursingHard
A patient says the voices are telling him to hurt his roommate. What should the nurse do first?
AIgnore it, because command hallucinations are common in schizophrenia and patients rarely act on them
BMove the roommate without telling anyone why
CAsk more about what the voices say and whether he feels he must obey, and ensure the safety of others
DTell him the voices are not real and leave
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 5 ft 4 in tall. Using 1 ft = 12 in and 1 in = 2.54 cm, find the height h in centimetres, to the nearest whole centimetre.
5 ft 4 in1 ft = 12 in1 in = 2.54 cm
h = cm
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 1½ tsp of an oral suspension four times a day for 14 days. The suspension comes in 100 mL bottles. Using 1 tsp = 5 mL, how many whole bottles N must be supplied so the course is complete?
1½ tspfour times a day14 days100 mL1 tsp = 5 mL
N =
27.Dosage calculationsMedium
A prefilled syringe of epinephrine (adrenaline) is labelled 1:10 000 (0.1 mg/mL). The prescription is 1 mg IV in cardiac arrest. What volume V do you give?
1:10 0001 mg
V = mL
28.Dosage calculationsHard
An infusion contains 25000 units of a drug in 250 mL. The prescription is 1000 units per hour. At what rate R do you set the pump, in mL/h?
25000 units/250 mL1000 units/h
R = mL/h
29.IV infusion ratesMedium
Infuse 250 mL over 3 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
250 mL3 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 30 gtt/min through a set of 20 gtt/mL. There are 750 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
30 gtt/min20 gtt/mL750 mL
t = 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 18 units/kg/h for a patient who weighs 83 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
20 000 units/500 mL18 units/kg/h83 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 400 mg in 250 mL. The order is 12 mcg/kg/min for a patient who weighs 92 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL12 mcg/kg/min92 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). Count ice chips as half their volume.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 120 mL/h. At 20:30, 350 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL350 mL infused120 mL/h
t = h
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: no; secondary diagnosis: no; ambulatory aid: holds on to furniture; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; 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). A practice patient is assessed with the Braden scale: sensory perception: completely limited; moisture: rarely moist; activity: bedfast; mobility: no limitation; nutrition: very poor; friction and shear: no apparent problem. Use the bands 19–23 not at risk, 15–18 mild, 13–14 moderate, 10–12 high and 9 or below very high. Click the risk level.
1not at risk
2mild risk
3moderate risk
4high risk
5very high risk
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 18 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 18 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 21% oxygen shows PaO₂ 76 mmHg (10.1 kPa) and PaCO₂ 40 mmHg (5.3 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
Interpret this lead II rhythm strip. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1junctional rhythm
2normal sinus rhythm
3first-degree AV block
4sinus bradycardia
40.ECG rhythm strip interpretationHard
Interpret this lead II strip. Which interpretation can you defend from this single 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
1second-degree AV block type II
2third-degree (complete) AV block
3second-degree AV block type I (Wenckebach)
42:1 AV block (type undetermined)
3Solutions
1.Nursing fundamentals
Answer: D · A loose stool that takes the shape of the container
Why this is the answer
Only diarrhoeal stool (types 5–7 on the Bristol Stool Chart) is tested for C. difficile. The sample is collected in a clean pot without urine contamination.
Answer
D · A loose stool that takes the shape of the container
2.Nursing fundamentals
Answer: D · Fluid overload
Why this is the answer
Breathlessness, crackles, raised respiratory rate and oedema during IV therapy suggest fluid overload. The nurse should stop or slow the infusion as appropriate, sit the patient up and escalate.
Answer
D · Fluid overload
3.Infection control & patient safety
Answer: D · Hold the bottle with the label in the palm and pour without touching the bowl
Why this is the answer
The nurse pours from a little height without touching the sterile bowl, avoiding splashes that would wet the field. Holding the label in the palm keeps it readable and free of drips.
Answer
D · Hold the bottle with the label in the palm and pour without touching the bowl
4.Infection control & patient safety
Answer: C · Into a red outlet connected to the emergency generator
Why this is the answer
In US hospitals, red outlets are usually connected to the emergency generator. Life-support equipment is plugged into them, and battery backups are checked as part of emergency planning.
Answer
C · Into a red outlet connected to the emergency generator
5.Prioritization & delegation
Answer: D · “I would like you to see him within 15 minutes and consider a fluid bolus.”
Why this is the answer
A good recommendation is specific about the request and the time frame. Vague statements leave the provider unsure how urgent the problem is.
Answer
D · “I would like you to see him within 15 minutes and consider a fluid bolus.”
6.Prioritization & delegation
Answer: A · A patient with neutropenia after chemotherapy
Why this is the answer
When urgency is equal, the nurse cares for the most vulnerable patient first and patients with transmissible infections last. This lowers the risk of carrying organisms to an immunocompromised patient.
Answer
A · A patient with neutropenia after chemotherapy
7.Clinical nursing
Answer: C · Hyperosmolar hyperglycaemic state
Why this is the answer
HHS usually affects people with type 2 diabetes. It develops over days with extreme hyperglycaemia, dehydration and high osmolality, but little ketosis.
Answer
C · Hyperosmolar hyperglycaemic state
8.Clinical nursing
Answer: B · Aortic dissection
Why this is the answer
Aortic dissection classically causes abrupt, tearing pain radiating to the back, with unequal arm pulses or pressures. It is a surgical emergency, and thrombolysis must not be given.
Answer
B · Aortic dissection
9.Lab values & electrolytes
Answer: D · A positive ANA supports lupus but does not diagnose it alone
Why this is the answer
Almost all patients with SLE have a positive ANA, so a negative test makes lupus unlikely. However, many healthy people and patients with other conditions also have a positive ANA, so diagnosis needs the clinical picture and more specific antibodies such as anti-dsDNA.Checked against:ANA (Antinuclear Antibody) Test · MedlinePlus (NIH) (2025)
Answer
D · A positive ANA supports lupus but does not diagnose it alone
10.Lab values & electrolytes
Answer: D · Cloudy fluid, low glucose, high protein, many neutrophils
Why this is the answer
Bacterial meningitis typically gives cloudy CSF with many neutrophils, high protein and low glucose, because bacteria and white cells use glucose. Viral meningitis usually shows lymphocytes with a normal glucose; option C is normal CSF.Checked against:CSF glucose test · MedlinePlus (NIH) (2025); CSF cell count · MedlinePlus (NIH) (2025); CSF total protein · MedlinePlus (NIH) (2025)
Answer
D · Cloudy fluid, low glucose, high protein, many neutrophils
11.Pharmacology
Answer: B · Stop the infusion, remove the cannula and elevate the limb
Why this is the answer
These signs suggest infiltration. The infusion is stopped and the cannula removed, the limb is elevated, and a new cannula is placed elsewhere; vesicant drugs need the extravasation protocol.
Answer
B · Stop the infusion, remove the cannula and elevate the limb
12.Pharmacology
Answer: B · Clarify the omission with the prescriber (medication reconciliation)
Why this is the answer
Medication reconciliation compares the patient's home medicines with current orders to find omissions, duplications and errors. The nurse raises the difference with the prescriber, who decides whether to continue, hold or change the drug.
Answer
B · Clarify the omission with the prescriber (medication reconciliation)
13.Med-surg: cardiovascular & respiratory
Answer: A · aPTT (or anti-Xa level)
Why this is the answer
IV unfractionated heparin has a variable effect and is titrated to the aPTT (or anti-Xa level) according to the prescribed protocol. The platelet count is also checked to detect heparin-induced thrombocytopenia. D-dimer is used to help exclude thrombosis, not to monitor treatment.
Answer
A · aPTT (or anti-Xa level)
14.Med-surg: cardiovascular & respiratory
Answer: C · A patient with heart failure who is newly confused, with SpO₂ 89%
Why this is the answer
New confusion with hypoxaemia suggests acute deterioration and needs immediate assessment. A COPD patient within their usual target range, a request for tea and an improving DVT are not urgent. Delegated observations must be reported and acted on promptly.
Answer
C · A patient with heart failure who is newly confused, with SpO₂ 89%
15.Med-surg: neuro, endocrine & renal
Answer: B · An expanding neck swelling with noisy breathing
Why this is the answer
A neck haematoma after carotid surgery can compress the airway quickly. It needs immediate senior help and may need the wound opened. Neurological checks for new stroke and cranial nerve damage are also part of routine care.
Answer
B · An expanding neck swelling with noisy breathing
16.Med-surg: neuro, endocrine & renal
Answer: D · A patient on insulin for DKA whose potassium is now 2.9 mmol/L
Why this is the answer
Insulin drives potassium into cells, and a potassium of 2.9 mmol/L during DKA treatment can cause life-threatening arrhythmias. The insulin rate and potassium replacement need urgent review under the protocol. The other patients are stable.
Answer
D · A patient on insulin for DKA whose potassium is now 2.9 mmol/L
17.Med-surg: GI, perioperative & oncology
Answer: A · It increases bleeding, wound infection and heart complications
Why this is the answer
Even mild hypothermia impairs clotting, increases surgical site infection and cardiac events, and causes shivering and discomfort. Forced-air warming, warmed fluids and covering the patient help prevent it.
Answer
A · It increases bleeding, wound infection and heart complications
18.Med-surg: GI, perioperative & oncology
Answer: A · Shallow breathing can lead to atelectasis and pneumonia
Why this is the answer
Uncontrolled chest wall pain prevents deep breaths and coughing, leading to atelectasis, sputum retention and pneumonia, particularly in older adults. Multimodal analgesia, sometimes with regional blocks, and physiotherapy are used.
Answer
A · Shallow breathing can lead to atelectasis and pneumonia
19.Maternity & obstetric nursing
Answer: A · A uterine infection (endometritis)
Why this is the answer
Foul-smelling lochia, especially with fever, uterine tenderness and tachycardia, suggests endometritis. It should be reported.
Answer
A · A uterine infection (endometritis)
20.Maternity & obstetric nursing
Answer: A · Call for help and lift the presenting part off the cord with a gloved hand
Why this is the answer
Relieve the pressure on the cord by keeping the presenting part off it, call for urgent help and use a knee–chest or head-down position. Do not try to replace the cord; if it is outside, it can be covered with warm, moist saline gauze. Birth is usually expedited.
Answer
A · Call for help and lift the presenting part off the cord with a gloved hand
21.Pediatric nursing
Answer: B · Place her in the recovery position and monitor airway and breathing
Why this is the answer
After a seizure, the child is placed on her side to keep the airway clear and let saliva drain. Breathing, colour and level of response are monitored, and nothing is given by mouth until she is fully alert.
Answer
B · Place her in the recovery position and monitor airway and breathing
22.Pediatric nursing
Answer: D · Acute rheumatic fever
Why this is the answer
Acute rheumatic fever follows group A streptococcal pharyngitis and causes migratory polyarthritis, carditis, rashes and chorea. Carditis can lead to rheumatic heart disease. Treating streptococcal sore throats prevents it.
Answer
D · Acute rheumatic fever
23.Mental health nursing
Answer: D · Hypothyroidism
Why this is the answer
Lithium can reduce thyroid hormone production, causing hypothyroidism. Thyroid function is checked regularly, and treatment with levothyroxine allows lithium to be continued if needed.
Answer
D · Hypothyroidism
24.Mental health nursing
Answer: C · Ask more about what the voices say and whether he feels he must obey, and ensure the safety of others
Why this is the answer
Command hallucinations to harm others need immediate assessment of content, intent and ability to resist them. The nurse keeps everyone safe, informs the team and documents the risk.
Answer
C · Ask more about what the voices say and whether he feels he must obey, and ensure the safety of others
25.Nursing math & unit conversions
Answer: h = 163 cm
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.
Height in inches
5·12 + 4 = 64 in
Inches to centimetres
h = 64·2.54 = 162.6 ≈ 163 cm
Answer
h = 163 cm
26.Nursing math & unit conversions
Answer: N = 5
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.
Total volume
7.5 mL × 4 × 14 = 420 mL
Bottles
420/100 = 4.2 → N = 5
Answer
N = 5
27.Dosage calculations
Answer: V = 10 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
Concentration
1:10 000 = 1 g/10000 mL = 0.1 mg/mL
Volume
V = 1/0.1 = 10 mL
Answer
V = 10 mL
US labels now state mg/mL (1 mg/mL = 1:1000; 0.1 mg/mL = 1:10 000). Never give 1 mg/mL epinephrine IV push.
28.Dosage calculations
Answer: R = 10 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
25000/250 = 100 units/mL
Pump rate
R = 1000/100 = 10 mL/h
Answer
R = 10 mL/h
29.IV infusion rates
Answer: R = 28 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
3·60 = 180 min
Drip rate
R = 250·20/180 = 27.78 ≈ 28 gtt/min
Answer
R = 28 gtt/min
At the bedside you round to the nearest whole drop: 28 gtt/min.
30.IV infusion rates
Answer: t = 8.3 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.
Rate in mL/h
30·60/20 = 90 mL/h
Time left
t = 750/90 = 8.333 ≈ 8.3 h
Answer
t = 8.3 h
31.Pediatric & critical-care dosing
Answer: R = 37.4 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
18·83 = 1 494 units/h
Concentration
20 000/500 = 40 units/mL
Pump rate
R = 1494/40 = 37.35 ≈ 37.4 mL/h
Answer
R = 37.4 mL/h
32.Pediatric & critical-care dosing
Answer: R = 41.4 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
400 mg = 400 000 mcg
400 000/250 = 1600 mcg/mL
Dose per minute and per hour
12·92 = 1104 mcg/min
1104·60 = 66240 mcg/h
Pump rate
R = 66240/1600 = 41.4 mL/h
Answer
R = 41.4 mL/h
33.IV fluids & fluid balance
Answer: B = 575 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 + 100 + 200 = 400 mL
ice chips: 200/2 = 100 mL
IV infusion: 100·8 = 800 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1350 mL
Total output
150 + 475 + 150 = 775 mL
Balance
B = 1350 − 775 = 575 mL
Answer
B = 575 mL
Positive: more fluid went in than came out.
34.IV fluids & fluid balance
Answer: t = 5.4 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
1000 − 350 = 650 mL
Time
t = 650/120 = 5.417 ≈ 5.4 h
Answer
t = 5.4 h
That is about 5 h 25 min, so the bag runs out at about 01:55.
35.Clinical assessment scores
Answer: MFS = 50
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: no → 0
secondary diagnosis: no → 0
ambulatory aid: holds on to furniture → 30
IV therapy or saline lock: yes → 20
gait: normal, bed rest or wheelchair → 0
mental status: knows own limits → 0
Add
Morse total = 0 + 0 + 30 + 20 + 0 + 0 = 50
Answer
MFS = 50
36.Clinical assessment scores
Answer: moderate risk
Braden scale: six subscales for pressure-injury risk. Sensory perception, moisture, activity, mobility and nutrition score 1 to 4, from the worst level (1) to no problem (4); friction and shear scores 1 to 3. The total runs from 6 to 23, and a lower total means a higher risk. Common bands: 19–23 not at risk, 15–18 mild risk, 13–14 moderate risk, 10–12 high risk and 9 or below very high risk.
Score each subscale
sensory perception: completely limited → 1
moisture: rarely moist → 4
activity: bedfast → 1
mobility: no limitation → 4
nutrition: very poor → 1
friction and shear: no apparent problem → 3
Add
Braden total = 1 + 4 + 1 + 4 + 1 + 3 = 14
Risk level
14 → moderate risk
Answer
moderate risk
37.Arterial blood gas interpretation
Answer: PaCO₂ = 35 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Winter’s formula
PaCO₂ = 1.5·18 + 8 = 35 mmHg
range: 33–37 mmHg
Answer
PaCO₂ = 35 mmHg
38.Arterial blood gas interpretation
Answer: A–a gradient = 23.73 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: R–R = 20 small boxes, 1500 ÷ 20 ≈ 75 per minute.
2. Rhythm: regular, every R–R is 0.80 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.34 s, constant, longer than 0.20 s.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
first-degree AV block
Answer
first-degree AV block
40.ECG rhythm strip interpretation
Answer: 2:1 AV block (type undetermined)
2:1 AV block: with two P waves for every QRS, no two conducted P waves follow each other, so you cannot see whether the PR would lengthen (type I) or stay constant (type II) before a non-conducted P wave. From one strip it is called a 2:1 AV block; a longer strip or a change in the conduction ratio decides the type. A narrow QRS makes type I more likely and a wide QRS type II, but neither proves it.
Five steps
1. Rate: R–R = 36 small boxes, 1500 ÷ 36 ≈ 42 per minute.
2. Rhythm: regular, every R–R is 1.44 s.
3. P waves: upright and regular (P–P 0.72 s, 83 per minute), two for every QRS.
4. PR interval: constant at 0.16 s in the conducted beats.
5. QRS: 0.10 s, narrow (below 0.12 s).
Why the type stays open
Every second P wave is not conducted, so no two conducted beats follow each other and a lengthening PR could never show.
2:1 AV block (type undetermined)
Answer
2:1 AV block (type undetermined)
A narrow QRS makes type I more likely and a wide QRS type II, but only a longer strip or a change in the conduction ratio decides.
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