Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
What is the purpose of a negative-pressure isolation room?
AAir flows into the room, so airborne particles do not escape into the corridor
BAir flows out of the room, keeping germs from the corridor away from the patient
CThe low pressure kills bacteria inside the room
DIt makes it easier for patients to breathe
2.Nursing fundamentalsHard
A nurse realises that a dose of analgesia given two hours ago was not documented. What is correct?
AWrite it now as a late entry, stating when it was given
BAsk a colleague to sign that they gave it
CWrite it in the space for two hours ago as if it was recorded then
DLeave it out, as it is now too late to record it in the notes
3.Infection control & patient safetyMedium
A patient has a weak left leg. Which instruction about using a cane is correct?
AHold the cane in the right hand, on the stronger side
BKeep the cane well out to the side, away from the body
CMove the cane and the right leg forward together
DHold the cane in the left hand, on the weaker side
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 any white outlet in the room
DInto a red outlet connected to the emergency generator
5.Prioritization & delegationMedium
A patient speaks little English, and the nurse needs to explain a new procedure. What is the best way to communicate?
ASpeak loudly and slowly in English
BUse hand gestures and hope the patient understands
CAsk the patient’s 10-year-old child to translate
DUse a professional medical interpreter
6.Prioritization & delegationHard
A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?
AThe risk of wound infection
BThe pain from the fracture
CThe suspected tension pneumothorax
DThe open fracture of the leg
7.Clinical nursingMedium
An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?
AGastric ulcer
BBiliary colic
CAppendicitis
DDiverticulitis
8.Clinical nursingHard
Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?
AIV syringes cannot hold liquid medicines
BTo prevent accidental intravenous administration
CEnteral syringes keep the medicine sterile
DEnteral syringes measure doses less accurately
9.Lab values & electrolytesMedium
When should blood cultures be taken for a patient with suspected sepsis?
AAfter the first three doses of antibiotics
BAt any time, since antibiotics do not affect the result
CBefore the first antibiotic dose, without delaying it much
DOnly if the fever lasts more than three days
10.Lab values & electrolytesHard
A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12.2 mmol/L), but the anion gap is still high. What change would the nurse expect?
AStop the insulin infusion because the glucose is near normal
BGive an IV bolus of sodium bicarbonate at once
CAdd dextrose to the IV fluids and continue the insulin
DStop the IV fluids and start oral fluids only
11.PharmacologyMedium
How should a patient take oral alendronate?
AWith milk at bedtime, then lying down straight away to aid absorption
BWith breakfast and coffee to protect the stomach
CWith plain water on an empty stomach, staying upright for 30 minutes
DCrushed into yoghurt with calcium supplements
12.PharmacologyHard
Morphine 4 mg IV is ordered. The ampoule contains 10 mg/mL. What volume should be drawn up?
A2.5 mL
B0.4 mL
C0.04 mL
D4 mL
13.Med-surg: cardiovascular & respiratoryMedium
A patient stops ramipril because of a troublesome dry cough. Which drug class is a common alternative?
AAn angiotensin II receptor blocker such as losartan
BA nitrate such as isosorbide mononitrate
CA loop diuretic such as furosemide
DA non-selective beta-blocker such as propranolol
14.Med-surg: cardiovascular & respiratoryHard
A patient with COPD who is known to retain CO₂ arrives on 15 L/min oxygen. They are now drowsy with SpO₂ 99%. What is the most appropriate action?
AGive a sedative to help the patient rest
BKeep the oxygen at 15 L/min because the saturation is excellent
CReduce the oxygen to aim for 88–92% and get a blood gas
DRemove the oxygen completely and observe
15.Med-surg: neuro, endocrine & renalMedium
A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?
AAvoiding large meals late in the evening
BRaising the head of the bed at night
CMagnesium-containing antacids
DEating smaller, more frequent meals
16.Med-surg: neuro, endocrine & renalHard
A nurse is caring for four patients. Which patient needs to be seen first?
AA patient with stable hypothyroidism due for levothyroxine
BA patient on peritoneal dialysis with clear effluent
CA patient after a craniotomy whose right pupil is newly dilated and slow to react
DA patient with CKD asking about their phosphate binder
17.Med-surg: GI, perioperative & oncologyMedium
Which statement about corticosteroids in inflammatory bowel disease is correct?
AThey are used to induce remission, not for maintenance
BThey are the best long-term maintenance treatment
CThey cure the disease after one course
DThey are given only as a one-off injection
18.Med-surg: GI, perioperative & oncologyHard
On day 3 after hip surgery, an older patient becomes acutely confused, with fluctuating attention and agitation. What should the nurse do first?
ALook for causes such as hypoxia, infection, pain or drugs, and escalate
BAssume that it is dementia and continue the care plan unchanged
CRestrain the patient and give a large dose of sedative straight away
DAsk the family to take the patient home so that they can settle
19.Maternity & obstetric nursingMedium
A pregnant woman takes warfarin for a mechanical heart valve. Why is she usually switched to heparin for much of the pregnancy?
AHeparin can be taken as a tablet once a day
BWarfarin is ineffective in pregnancy
CHeparin crosses the placenta better and also protects the fetus
DWarfarin crosses the placenta and can harm the fetus
20.Maternity & obstetric nursingHard
Monochorionic twins at 22 weeks show one twin with polyhydramnios and a large bladder and the other with almost no fluid. What condition is suspected?
AGestational diabetes in one twin
BTwin-to-twin transfusion syndrome
CPlacenta praevia
DRh isoimmunisation
21.Pediatric nursingMedium
How should a nurse approach a health interview with a 15-year-old?
ASpend part of the visit alone with the adolescent and explain the limits of confidentiality
BTell the adolescent that everything said will be shared with the parents to keep them informed
CInterview the adolescent with friends present for support
DSpeak only to the parent
22.Pediatric nursingHard
The 7-year-old brother of a child with cancer has started misbehaving at school. What is the most likely explanation?
AIt is unrelated to the illness and is normal for his age
BHe has developed attention deficit hyperactivity disorder and needs medicine
CHe may feel worried, jealous or left out and needs attention and information
DHe is copying behaviour from other children in his class
23.Mental health nursingMedium
Which side effects are most common with quetiapine?
AA cough and swollen ankles
BHigh prolactin with breast enlargement in almost every patient
CSedation, dizziness when standing and weight gain
DInsomnia and severe weight loss
24.Mental health nursingHard
On the third day of refeeding, a patient with severe anorexia nervosa develops swollen ankles, a low phosphate and an irregular pulse. What is most likely?
ANormal weight gain
BRefeeding syndrome
CAn allergic reaction to the food
DSerotonin syndrome
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 04:00 (24-hour clock). Which entry is the same time on the 12-hour clock? Click it.
04:00
16:00 AM
24:00 PM
33:00 AM
44:00 AM
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes 8 fl oz of juice, 3 tbsp of liquid supplement, 1½ tsp of cough syrup, 3 cups of tea. Using the equivalents given, find the total oral intake V in mL.
1 fl oz = 30 mL1 tbsp = 15 mL1 tsp = 5 mL1 cup = 8 fl oz = 240 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 22 kg and is prescribed 10 mg/kg as a single dose. Find the dose D in mg.
22 kg10 mg/kg
D = mg
28.Dosage calculationsHard
The prescription is 4400 units of a drug that comes as 10000 units/mL. Draw up the dose in the 1 mL syringe: what volume V do you give?
4400 units10000 units/mL
V = mL
29.IV infusion ratesMedium
Infuse 500 mL over 8 hours with a giving set of 15 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
500 mL8 h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
1500 mL was ordered over 8 hours. After 3 hours you find that 1160 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1500 mL / 8 hafter 3 h: 1160 mL
Δ = %
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A bag contains 25 000 units of heparin in 250 mL. The order is 16 units/kg/h for a patient who weighs 71 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL16 units/kg/h71 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 800 mg in 500 mL. The order is 10 mcg/kg/min for a patient who weighs 58 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
800 mg/500 mL10 mcg/kg/min58 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 patient weighs 48 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
48 kg8 hurine: 300 mLurine: 200 mLurine: 475 mL
U = mL/kg/h
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL infusion starts at 17:00 at 75 mL/h. After 2 hours the rate is changed to 80 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
500 mL75 mL/h · 2 h80 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: completely limited; moisture: constantly moist; activity: walks occasionally; mobility: completely immobile; nutrition: probably inadequate; friction and shear: no apparent problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: no impairment; moisture: occasionally moist; activity: walks occasionally; mobility: no limitation; nutrition: probably inadequate; 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
Practice values: Na⁺ 133 mmol/L, glucose 15.9 mmol/L and urea 14.2 mmol/L. Calculate the serum osmolality Osm = 2·Na⁺ + glucose + urea to the nearest whole number.
Na⁺ 133 mmol/Lglucose 15.9 mmol/Lurea 14.2 mmol/L
Osm = mOsm/kg
38.Arterial blood gas interpretationHard
A practice gas shows a respiratory acidosis: pH 7.24, PaCO₂ 80 mmHg (10.7 kPa), HCO₃⁻ 33 mmol/L. Use the rules ‘HCO₃⁻ rises 1 mmol/L per 10 mmHg (acute) or 3.5 mmol/L per 10 mmHg (chronic)’ to classify it. Click your answer.
pH 7.24PaCO₂ 80 mmHg (10.7 kPa)HCO₃⁻ 33 mmol/L
1acute
2chronic
3acute on chronic
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
2supraventricular tachycardia (SVT)
3ventricular tachycardia
4accelerated junctional rhythm
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
1junctional rhythm
2first-degree AV block
3third-degree (complete) AV block
4second-degree AV block type II
3Solutions
1.Nursing fundamentals
Answer: A · Air flows into the room, so airborne particles do not escape into the corridor
Why this is the answer
Negative pressure draws air into the room and out through filtered exhaust. It is used for airborne infections such as tuberculosis; positive pressure is used to protect patients with very weak immunity.
Answer
A · Air flows into the room, so airborne particles do not escape into the corridor
2.Nursing fundamentals
Answer: A · Write it now as a late entry, stating when it was given
Why this is the answer
Late entries are clearly marked as such, showing both when care was given and when the note was written. This keeps the record accurate and prevents a second dose being given.
Answer
A · Write it now as a late entry, stating when it was given
3.Infection control & patient safety
Answer: A · Hold the cane in the right hand, on the stronger side
Why this is the answer
The cane is held on the strong side and moved forward with the weak leg, so it shares the weight that the weak leg cannot take. It is kept close to the body for stability.
Answer
A · Hold the cane in the right hand, on the stronger side
4.Infection control & patient safety
Answer: D · 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
D · Into a red outlet connected to the emergency generator
5.Prioritization & delegation
Answer: D · Use a professional medical interpreter
Why this is the answer
Professional interpreters give accurate, confidential translation of medical information. Family members, especially children, may leave things out and should not be used for important explanations.
Answer
D · Use a professional medical interpreter
6.Prioritization & delegation
Answer: C · The suspected tension pneumothorax
Why this is the answer
A shifted trachea, absent breath sounds and hypotension suggest tension pneumothorax, which threatens breathing and circulation within minutes. The fracture is important, but it comes after the immediate life threat.
Answer
C · The suspected tension pneumothorax
7.Clinical nursing
Answer: D · Diverticulitis
Why this is the answer
Diverticulitis is inflammation of diverticula, usually in the sigmoid colon, so pain is typically in the left iliac fossa. It is common in older adults.
Answer
D · Diverticulitis
8.Clinical nursing
Answer: B · To prevent accidental intravenous administration
Why this is the answer
Giving an oral or enteral medicine intravenously can be fatal. Enteral syringes with non-IV connectors, such as ENFit, make this wrong-route error much less likely.
Answer
B · To prevent accidental intravenous administration
9.Lab values & electrolytes
Answer: C · Before the first antibiotic dose, without delaying it much
Why this is the answer
Blood cultures are taken before antibiotics, because even one dose can prevent bacteria from growing and hide the cause. Antibiotics should still be started quickly, ideally within an hour.Checked against:Sepsis · MedlinePlus (NIH) (2024)
Answer
C · Before the first antibiotic dose, without delaying it much
10.Lab values & electrolytes
Answer: C · Add dextrose to the IV fluids and continue the insulin
Why this is the answer
The glucose usually falls before the ketoacidosis resolves. Dextrose is added so insulin can continue, clearing ketones without causing hypoglycemia, until the anion gap closes. Stopping insulin too early lets ketoacidosis return.
Answer
C · Add dextrose to the IV fluids and continue the insulin
11.Pharmacology
Answer: C · With plain water on an empty stomach, staying upright for 30 minutes
Why this is the answer
Alendronate is taken first thing in the morning with water only, before food or other drugs. Staying upright reduces the risk of oesophageal ulceration, and food or calcium blocks its absorption.
Answer
C · With plain water on an empty stomach, staying upright for 30 minutes
12.Pharmacology
Answer: B · 0.4 mL
Why this is the answer
4 mg ÷ 10 mg/mL = 0.4 mL. The unused remainder of a controlled drug is discarded with a witness.
Answer
B · 0.4 mL
13.Med-surg: cardiovascular & respiratory
Answer: A · An angiotensin II receptor blocker such as losartan
Why this is the answer
Angiotensin receptor blockers (ending in -sartan) block the effects of angiotensin II without inhibiting ACE, so bradykinin does not build up and cough is much less common. They share other effects, such as raising potassium, and ACE inhibitors and ARBs are not normally combined.
Answer
A · An angiotensin II receptor blocker such as losartan
14.Med-surg: cardiovascular & respiratory
Answer: C · Reduce the oxygen to aim for 88–92% and get a blood gas
Why this is the answer
In patients at risk of hypercapnic respiratory failure, excess oxygen can raise PaCO₂ and cause drowsiness and acidosis. Oxygen is stepped down to a target of 88–92% (for example via a Venturi mask), not stopped abruptly, which could cause dangerous hypoxaemia. An arterial blood gas guides further treatment, which may include NIV.
Answer
C · Reduce the oxygen to aim for 88–92% and get a blood gas
15.Med-surg: neuro, endocrine & renal
Answer: C · Magnesium-containing antacids
Why this is the answer
Magnesium and aluminium are excreted by the kidneys and can accumulate in kidney failure. Patients with CKD should check with a pharmacist before using over-the-counter remedies, including laxatives and NSAIDs.
Answer
C · Magnesium-containing antacids
16.Med-surg: neuro, endocrine & renal
Answer: C · A patient after a craniotomy whose right pupil is newly dilated and slow to react
Why this is the answer
A new, one-sided dilated and sluggish pupil after brain surgery suggests rising intracranial pressure pressing on the oculomotor nerve, a possible sign of brain herniation. It needs immediate assessment, including the GCS and vital signs, and urgent escalation. The other patients are stable, and their needs can be met shortly afterwards.
Answer
C · A patient after a craniotomy whose right pupil is newly dilated and slow to react
17.Med-surg: GI, perioperative & oncology
Answer: A · They are used to induce remission, not for maintenance
Why this is the answer
Steroids settle flares but are not effective or safe for maintenance because of side effects such as osteoporosis, diabetes and infection. Drugs such as aminosalicylates, immunomodulators or biologics maintain remission.
Answer
A · They are used to induce remission, not for maintenance
18.Med-surg: GI, perioperative & oncology
Answer: A · Look for causes such as hypoxia, infection, pain or drugs, and escalate
Why this is the answer
Acute confusion with fluctuating attention suggests delirium. It is a medical emergency with many possible causes, such as hypoxia, sepsis, pain, drugs (including opioids and anticholinergics), urinary retention, constipation, dehydration and electrolyte problems. Treat the cause, use non-drug measures, and use sedation only as a last resort.
Answer
A · Look for causes such as hypoxia, infection, pain or drugs, and escalate
19.Maternity & obstetric nursing
Answer: D · Warfarin crosses the placenta and can harm the fetus
Why this is the answer
Warfarin crosses the placenta and is teratogenic and can cause fetal bleeding. Heparins are large molecules that do not cross the placenta, so low molecular weight heparin is commonly used instead.
Answer
D · Warfarin crosses the placenta and can harm the fetus
20.Maternity & obstetric nursing
Answer: B · Twin-to-twin transfusion syndrome
Why this is the answer
In monochorionic twins, unbalanced vascular connections can shunt blood from one twin to the other. The recipient becomes overloaded with polyhydramnios, while the donor has low fluid and growth restriction.
Answer
B · Twin-to-twin transfusion syndrome
21.Pediatric nursing
Answer: A · Spend part of the visit alone with the adolescent and explain the limits of confidentiality
Why this is the answer
Adolescents are more open when interviewed alone. Explain that what they say is confidential unless there is a risk of serious harm. Frameworks such as HEADSSS cover home, education, activities, drugs, sexuality, suicide and safety.
Answer
A · Spend part of the visit alone with the adolescent and explain the limits of confidentiality
22.Pediatric nursing
Answer: C · He may feel worried, jealous or left out and needs attention and information
Why this is the answer
Siblings of seriously ill children often feel neglected, anxious, guilty or jealous and may show this through behaviour changes. Family-centred care includes giving siblings age-appropriate information, involvement and time with parents.
Answer
C · He may feel worried, jealous or left out and needs attention and information
23.Mental health nursing
Answer: C · Sedation, dizziness when standing and weight gain
Why this is the answer
Quetiapine commonly causes drowsiness, orthostatic hypotension and metabolic effects. It has a lower risk of extrapyramidal effects and raised prolactin than many other antipsychotics.
Answer
C · Sedation, dizziness when standing and weight gain
24.Mental health nursing
Answer: B · Refeeding syndrome
Why this is the answer
Refeeding after starvation causes insulin release that drives phosphate, potassium and magnesium into cells, causing heart failure, oedema, arrhythmias and confusion. Electrolytes are monitored closely and replaced, and feeding is increased gradually.
Answer
B · Refeeding syndrome
25.Nursing math & unit conversions
Answer: 4:00 AM
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Convert the hour
04 → 4 AM
Answer
4:00 AM
Answer
4:00 AM
26.Nursing math & unit conversions
Answer: V = 1013 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
8 fl oz = 8·30 = 240 mL
3 tbsp = 3·15 = 45 mL
1½ tsp = 1.5·5 = 7.5 mL
3 cups = 3·240 = 720 mL
Add
V = 240 + 45 + 7.5 + 720 = 1013 mL
Answer
V = 1013 mL
27.Dosage calculations
Answer: D = 220 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
10·22 = 220 mg
Answer
D = 220 mg
28.Dosage calculations
Answer: V = 0.44 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Volume
V = 4400/10000 = 0.44 mL
On the syringe
On this 1 mL syringe every small line is 0.01 mL.
Answer
V = 0.44 mL
29.IV infusion rates
Answer: R = 16 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
8·60 = 480 min
Drip rate
R = 500·15/480 = 15.63 ≈ 16 gtt/min
Answer
R = 16 gtt/min
At the bedside you round to the nearest whole drop: 16 gtt/min.
30.IV infusion rates
Answer: Δ = 23.73 %
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
1500/8 = 187.5 mL/h
New rate
R = 1160/5 = 232 mL/h
Percentage change
Δ = (232 − 187.5)/187.5·100% = 23.73%
Answer
Δ = 23.73%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.Pediatric & critical-care dosing
Answer: R = 11.4 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
16·71 = 1 136 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1136/100 = 11.36 ≈ 11.4 mL/h
Answer
R = 11.4 mL/h
32.Pediatric & critical-care dosing
Answer: R = 21.8 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
800 mg = 800 000 mcg
800 000/500 = 1600 mcg/mL
Dose per minute and per hour
10·58 = 580 mcg/min
580·60 = 34800 mcg/h
Pump rate
R = 34800/1600 = 21.75 ≈ 21.8 mL/h
Answer
R = 21.8 mL/h
33.IV fluids & fluid balance
Answer: U = 2.54 mL/kg/h
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total urine
300 + 200 + 475 = 975 mL
Per kilogram per hour
U = 975/(48·8) = 2.539 ≈ 2.54 mL/kg/h
Answer
U = 2.54 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 6.4 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.
First part
75·2 = 150 mL
500 − 150 = 350 mL left
Second part
350/80 = 4.375 h
Total time
t = 2 + 4.375 = 6.375 ≈ 6.4 h
Answer
t = 6.4 h
That is about 6 h 23 min, so the bag runs out at about 23:23.
35.Clinical assessment scores
Answer: B = 11
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: constantly moist → 1
activity: walks occasionally → 3
mobility: completely immobile → 1
nutrition: probably inadequate → 2
friction and shear: no apparent problem → 3
Add
Braden total = 1 + 1 + 3 + 1 + 2 + 3 = 11
Answer
B = 11
36.Clinical assessment scores
Answer: not at 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: no impairment → 4
moisture: occasionally moist → 3
activity: walks occasionally → 3
mobility: no limitation → 4
nutrition: probably inadequate → 2
friction and shear: no apparent problem → 3
Add
Braden total = 4 + 3 + 3 + 4 + 2 + 3 = 19
Risk level
19 → not at risk
Answer
not at risk
37.Arterial blood gas interpretation
Answer: Osm = 296 mOsm/kg
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.
Calculated osmolality
Osm = 2·133 + 15.9 + 14.2 = 296.1 ≈ 296 mOsm/kg
Answer
Osm = 296 mOsm/kg
38.Arterial blood gas interpretation
Answer: acute on chronic
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 HCO₃⁻
acute: 24 + 1·4 = 28 mmol/L
chronic: 24 + 3.5·4 = 38 mmol/L
Compare
measured: 33 mmol/L → acute on chronic
Answer
acute on chronic
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 = 10 small boxes, 1500 ÷ 10 ≈ 150 per minute.
2. Rhythm: regular, every R–R is 0.40 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: third-degree (complete) AV block
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: R–R = 28 small boxes, 1500 ÷ 28 ≈ 54 per minute.
2. Rhythm: R–R regular (1.12 s) and P–P regular (0.80 s), but the two are independent.
3. P waves: upright and regular at 75 per minute, but not linked to the QRS complexes; some hide in a QRS or a T wave.
4. PR interval: varies from beat to beat; there is no fixed relation.
5. QRS: 0.06 s, narrow (below 0.12 s).
Interpretation
third-degree (complete) AV block
Answer
third-degree (complete) AV block
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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