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 says, "I've never seen this tablet before," as the nurse offers it. What should the nurse do?
AGive half the tablet until the doctor visits
BStop and recheck the prescription before giving it
CLeave the tablet on the table for the patient to take later
DReassure the patient that the tablet is correct and give it
2.Nursing fundamentalsHard
Why must a needlestick injury be reported straight away rather than at the end of the shift?
AThe injury must be documented within ten minutes for the report to be valid
BThe source patient will be discharged soon
CReporting late means the nurse has to pay for the tests
DPost-exposure prophylaxis works best when it is started as soon as possible
3.Infection control & patient safetyMedium
A patient has a weak left leg. Which instruction about using a cane is correct?
AMove the cane and the right leg forward together
BHold the cane in the left hand, on the weaker side
CKeep the cane well out to the side, away from the body
DHold the cane in the right hand, on the stronger side
4.Infection control & patient safetyHard
A confused patient in wrist restraints has cool, pale fingers on one hand and a weak radial pulse on that side. What should the nurse do first?
ADocument the findings carefully and recheck in two hours
BLoosen that restraint and assess the hand’s circulation
CTighten the other restraint to stop the patient pulling
DRaise the hand on a pillow, leaving the restraint as it is
5.Prioritization & delegationMedium
A patient with severe neutropenia needs a room. Which roommate is the safest choice?
AA patient after a knee replacement with no signs of infection
BA patient with C. difficile diarrhea
CA patient with influenza
DA patient with an infected, draining leg wound
6.Prioritization & delegationHard
Which patient on a renal unit should the nurse see first?
AA patient asking for advice about a low-phosphate diet
BA patient on peritoneal dialysis whose drained fluid is clear
CA patient whose arteriovenous fistula has a strong thrill and bruit
DA patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
7.Clinical nursingMedium
Which group of symptoms suggests hypothyroidism?
AWeight loss, heat intolerance and tremor
BTiredness, weight gain and feeling cold
CExcessive thirst and passing large volumes of urine
DFever, neck stiffness and photophobia
8.Clinical nursingHard
A patient on enteral tube feeding after a long period of starvation develops low phosphate, low potassium and arrhythmias. What is most likely?
ARefeeding syndrome
BHyperthyroidism
CDumping syndrome
DDiabetic ketoacidosis
9.Lab values & electrolytesMedium
A patient with sepsis has a lactate of 2.1 mmol/L on admission and 4.3 mmol/L two hours later, despite IV fluids. What does this suggest?
AImproving circulation as the fluids start to work
BWorsening tissue perfusion that needs urgent reporting
CA normal response to IV fluids in the first hours
DExpected muscle activity from shivering in fever
10.Lab values & electrolytesHard
A patient's total calcium is 7.6 mg/dL and the albumin is 2.0 g/dL. Using the common correction (add 0.8 mg/dL for each 1 g/dL that albumin is below 4.0), what is the corrected calcium?
A7.6 mg/dL, below the normal range
B6.0 mg/dL, well below the normal range
C9.2 mg/dL, within the normal range
D11.6 mg/dL, above the normal range
11.PharmacologyMedium
Combining an SSRI with which drug most increases the risk of serotonin syndrome?
AA monoamine oxidase inhibitor
BParacetamol
COmeprazole
DAmoxicillin
12.PharmacologyHard
Why is pyridoxine (vitamin B6) often given together with isoniazid for tuberculosis?
ATo prevent liver damage from isoniazid
BTo increase the absorption of isoniazid
CTo prevent peripheral neuropathy
DTo reduce bacterial resistance
13.Med-surg: cardiovascular & respiratoryMedium
A patient is going home with a 24-hour Holter monitor. Which instruction is most important?
AKeep a diary of symptoms and activities with the times
BRemove the monitor whenever symptoms occur and restart it
CStay in bed for the full 24 hours so the trace is clear
DShower as normal with the monitor on
14.Med-surg: cardiovascular & respiratoryHard
A 70-year-old man has a small abdominal aortic aneurysm found on screening and is placed under surveillance. Which advice is most important?
AStop all blood pressure medicines to avoid low pressure
BHave the aneurysm repaired immediately, whatever its size or growth rate
CStop smoking, control BP and seek help at once for sudden back pain
DAvoid all exercise and lifting for the rest of his life to protect the aorta
15.Med-surg: neuro, endocrine & renalMedium
Fifteen minutes after treatment with glucose tablets, a patient's glucose has risen from 3.2 to 5.1 mmol/L. Their next meal is in two hours. What should happen next?
AGive another dose of glucose tablets to push it higher
BGive the usual dose of rapid-acting insulin straight away
CNo further action is needed until the next meal is served later
DGive a longer-acting carbohydrate snack, such as a sandwich
16.Med-surg: neuro, endocrine & renalHard
A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?
AThe patient may not be absorbing their immunosuppressants
BVomiting proves that rejection has already happened
CThe kidney will start to produce far too much urine
DThe tablets will make the vomiting stop
17.Med-surg: GI, perioperative & oncologyMedium
Why is the time a surgical limb tourniquet is inflated carefully recorded?
AThe tourniquet slowly loses all its air after one minute
BIt shows how long the anaesthetic gas was used
CLong inflation can cause nerve and muscle damage
DThe surgeon is paid per minute of use
18.Med-surg: GI, perioperative & oncologyHard
A patient with cirrhosis takes spironolactone and furosemide. Which blood result should the nurse report before the next dose?
APotassium 4.2 mmol/L
BSodium 141 mmol/L
CSodium 138 mmol/L
DPotassium 6.0 mmol/L
19.Maternity & obstetric nursingMedium
Which findings are typical of placental abruption?
APainless bright red bleeding with a soft, relaxed, non-tender uterus
BAbdominal pain, a firm or rigid uterus and dark red bleeding
CLeaking clear fluid without contractions
DItching of the palms and soles
20.Maternity & obstetric nursingHard
A preterm baby is being prepared for discharge. Which statement by the parents shows understanding of kangaroo (skin-to-skin) care?
A"Skin-to-skin increases her risk of getting cold."
B"Skin-to-skin is only for full-term babies."
C"She should be fully dressed and wrapped before I hold her."
D"Holding her on my bare chest keeps her warm."
21.Pediatric nursingMedium
A 6-month-old's left eye turns inwards all the time. What should the nurse do?
AReassure the parents that this always resolves by school age
BAdvise them to wait until the child can read letters
CCover the right eye with a patch at home without review
DRefer the baby to an eye specialist
22.Pediatric nursingHard
A child with a head injury now has rising blood pressure, a falling heart rate and irregular breathing. What does this indicate?
ADehydration that needs more fluids
BPain from the injury that needs stronger, regular analgesia
CA late sign of raised intracranial pressure; an emergency
DNormal recovery after a head injury
23.Mental health nursingMedium
How does memantine work in Alzheimer's disease?
AIt increases serotonin by blocking its reuptake
BIt blocks NMDA glutamate receptors
CIt inhibits the breakdown of acetylcholine
DIt blocks dopamine D2 receptors
24.Mental health nursingHard
A patient taking an MAOI returns from a party with a severe headache at the back of the head, a stiff neck and palpitations. What should the nurse do first?
ACheck the blood pressure and notify the prescriber urgently
BGive a cup of strong coffee for the headache
CAdvise her to lie down and sleep it off
DGive her next MAOI dose early
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose is charted at 5:00 AM. Which entry is the same time on the 24-hour clock? Click it.
5:00 AM
106:00
205:00
317:00
404:00
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 20:40 and finishes at 00:10 the next morning (24-hour clock). How many minutes t did it run?
20:4000:10
t = min
27.Dosage calculationsMedium
How many milligrams of drug m are in 2 mL of a 5% (w/v) solution?
5% w/v2 mL
m = mg
28.Dosage calculationsHard
A patient is 175 cm tall and weighs 75 kg. The prescription is 50 mg/m². Using the Mosteller formula BSA = √(height (cm) × weight (kg)/3600), find the dose D in mg.
175 cm75 kg50 mg/m²
D = mg
29.IV infusion ratesMedium
Infuse 250 mL over 12 hours with a giving set of 60 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
250 mL12 h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A bag contains 4 g of a drug in 500 mL. The order is 4 mg per minute. At what rate R do you set the pump, in mL/h?
4 g/500 mL4 mg/min
R = mL/h
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). An infusion of 50 units of regular insulin in 50 mL runs at 2 mL/h. How many units per hour D does the patient receive?
50 units/50 mL2 mL/h
D = units/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 250 mg in 250 mL runs at 6 mL/h. The patient weighs 62 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
250 mg/250 mL6 mL/h62 kg
D = mcg/kg/min
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 8-hour shift. The patient weighs 61 kg. Find the average urine output U in mL/kg/h. Round to two decimal places.
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 80 mL/h. At 06:00, 50 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL50 mL infused80 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A patient has a pulse of 104/min and a blood pressure of 77/42 mmHg. Find the shock index SI = HR/SBP. Round to two decimal places.
HR 104/minBP 77/42 mmHg
SI =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Braden scale: sensory perception: very limited; moisture: rarely moist; activity: walks frequently; mobility: no limitation; nutrition: excellent; 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 arterial blood gas shows pH 7.53, PaCO₂ 47 mmHg (6.3 kPa) and HCO₃⁻ 38 mmol/L. The primary disorder is metabolic alkalosis. How far is it compensated? Click your answer.
pH 7.53PaCO₂ 47 mmHg (6.3 kPa)HCO₃⁻ 38 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 43 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 43 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
2supraventricular tachycardia (SVT)
3sinus tachycardia
4atrial flutter, 2:1 conduction
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
1sinus bradycardia
2second-degree AV block type II
3first-degree AV block
4second-degree AV block type I (Wenckebach)
3Solutions
1.Nursing fundamentals
Answer: B · Stop and recheck the prescription before giving it
Why this is the answer
A patient questioning a medicine may be a sign of an error. The nurse holds the dose, checks the prescription and the drug and explains before giving it.
Answer
B · Stop and recheck the prescription before giving it
2.Nursing fundamentals
Answer: D · Post-exposure prophylaxis works best when it is started as soon as possible
Why this is the answer
After a high-risk exposure, for example to HIV or hepatitis B, preventive treatment is most effective when started early. Prompt reporting also allows the source patient to be assessed.
Answer
D · Post-exposure prophylaxis works best when it is started as soon as possible
3.Infection control & patient safety
Answer: D · 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
D · Hold the cane in the right hand, on the stronger side
4.Infection control & patient safety
Answer: B · Loosen that restraint and assess the hand’s circulation
Why this is the answer
Signs of poor circulation distal to a restraint require immediate release and assessment. The restraint is then reapplied correctly only if still needed, with the two-finger check, and the findings are reported and documented.
Answer
B · Loosen that restraint and assess the hand’s circulation
5.Prioritization & delegation
Answer: A · A patient after a knee replacement with no signs of infection
Why this is the answer
A neutropenic patient cannot fight infection well, so the roommate must not have a transmissible infection. A clean postoperative patient is the safest choice; ideally the neutropenic patient has a single room.
Answer
A · A patient after a knee replacement with no signs of infection
6.Prioritization & delegation
Answer: D · A patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
Why this is the answer
A missed dialysis session lets potassium build up. Muscle weakness and an irregular pulse suggest hyperkalemia, which can cause fatal arrhythmias, so the nurse assesses at once, arranges cardiac monitoring and escalates. A thrill and bruit and clear effluent are expected findings, and diet advice can wait.
Answer
D · A patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
7.Clinical nursing
Answer: B · Tiredness, weight gain and feeling cold
Why this is the answer
Low thyroid hormone slows metabolism, causing fatigue, weight gain, cold intolerance, constipation, dry skin and bradycardia. Weight loss, heat intolerance and tremor suggest hyperthyroidism.
Answer
B · Tiredness, weight gain and feeling cold
8.Clinical nursing
Answer: A · Refeeding syndrome
Why this is the answer
Refeeding syndrome results from rapid shifts of phosphate, potassium and magnesium into cells when feeding resumes. High-risk patients start slowly with electrolyte monitoring and thiamine.
Answer
A · Refeeding syndrome
9.Lab values & electrolytes
Answer: B · Worsening tissue perfusion that needs urgent reporting
Why this is the answer
A rising lactate despite fluids suggests ongoing tissue hypoperfusion and worsening sepsis or septic shock. The nurse reports it at once; further fluids, vasopressors and source control may be needed, and lactate is remeasured.Checked against:Lactate Test · MedlinePlus (NIH) (2024); Septic shock · MedlinePlus (NIH) (2025)
Answer
B · Worsening tissue perfusion that needs urgent reporting
10.Lab values & electrolytes
Answer: C · 9.2 mg/dL, within the normal range
Why this is the answer
Corrected calcium = 7.6 + 0.8 × (4.0 − 2.0) = 9.2 mg/dL, which is normal. Low albumin lowers the bound fraction of calcium; the correction is only an estimate, and an ionized calcium is more accurate when it matters.Checked against:Calcium blood test · MedlinePlus (NIH) (2025)
Answer
C · 9.2 mg/dL, within the normal range
11.Pharmacology
Answer: A · A monoamine oxidase inhibitor
Why this is the answer
SSRIs block serotonin reuptake and MAO inhibitors block its breakdown. Together they can cause serotonin syndrome with agitation, hyperthermia, tremor and clonus.
Answer
A · A monoamine oxidase inhibitor
12.Pharmacology
Answer: C · To prevent peripheral neuropathy
Why this is the answer
Isoniazid causes pyridoxine deficiency, which can lead to peripheral neuropathy. The risk is greater in slow acetylators, malnourished patients and people with diabetes or alcohol dependence.
Answer
C · To prevent peripheral neuropathy
13.Med-surg: cardiovascular & respiratory
Answer: A · Keep a diary of symptoms and activities with the times
Why this is the answer
A Holter monitor records the ECG continuously during normal daily life. A diary of symptoms and activities lets the reviewer match symptoms such as palpitations or dizziness to the rhythm. The device is kept dry unless it is designed to be waterproof.
Answer
A · Keep a diary of symptoms and activities with the times
14.Med-surg: cardiovascular & respiratory
Answer: C · Stop smoking, control BP and seek help at once for sudden back pain
Why this is the answer
Small aneurysms are usually monitored with regular ultrasound, with repair considered when they reach a threshold size or grow fast. Stopping smoking slows growth, and BP and cardiovascular risk are managed. Sudden abdominal or back pain may mean rupture and needs emergency care.
Answer
C · Stop smoking, control BP and seek help at once for sudden back pain
15.Med-surg: neuro, endocrine & renal
Answer: D · Give a longer-acting carbohydrate snack, such as a sandwich
Why this is the answer
Once glucose is above 4 mmol/L, a longer-acting carbohydrate (or the next meal if it is due) prevents a recurrence. The cause of the hypoglycaemia should be identified and documented, and the treatment plan reviewed if episodes recur.
Answer
D · Give a longer-acting carbohydrate snack, such as a sandwich
16.Med-surg: neuro, endocrine & renal
Answer: A · The patient may not be absorbing their immunosuppressants
Why this is the answer
Vomiting and diarrhoea can reduce absorption of immunosuppressants, raising the risk of rejection, and dehydration can harm the graft. Tacrolimus levels can also rise with diarrhoea. The team may check levels and kidney function.
Answer
A · The patient may not be absorbing their immunosuppressants
17.Med-surg: GI, perioperative & oncology
Answer: C · Long inflation can cause nerve and muscle damage
Why this is the answer
A tourniquet creates a bloodless field but causes limb ischaemia. Inflation time and pressure are recorded and the surgeon is told at set intervals, as long inflation can damage nerves and muscle.
Answer
C · Long inflation can cause nerve and muscle damage
18.Med-surg: GI, perioperative & oncology
Answer: D · Potassium 6.0 mmol/L
Why this is the answer
Spironolactone blocks aldosterone and can cause hyperkalaemia, which risks arrhythmias. A potassium of 6.0 mmol/L is above the normal range (about 3.5–5.0) and needs urgent review before further doses.
Answer
D · Potassium 6.0 mmol/L
19.Maternity & obstetric nursing
Answer: B · Abdominal pain, a firm or rigid uterus and dark red bleeding
Why this is the answer
Abruption causes pain, uterine tenderness and rigidity, and dark bleeding. The bleeding can be hidden behind the placenta, so blood loss may be much larger than what is visible.
Answer
B · Abdominal pain, a firm or rigid uterus and dark red bleeding
20.Maternity & obstetric nursing
Answer: D · "Holding her on my bare chest keeps her warm."
Why this is the answer
Kangaroo care places the baby in a nappy against the parent's bare chest. It stabilises temperature, heart rate and breathing, supports breastfeeding and bonding, and is beneficial for preterm babies.
Answer
D · "Holding her on my bare chest keeps her warm."
21.Pediatric nursing
Answer: D · Refer the baby to an eye specialist
Why this is the answer
An occasional squint is common in the first months, but a constant squint, or any squint after about 4–6 months, needs specialist assessment. Without treatment, the brain may suppress the image from the turning eye, causing amblyopia.
Answer
D · Refer the baby to an eye specialist
22.Pediatric nursing
Answer: C · A late sign of raised intracranial pressure; an emergency
Why this is the answer
Hypertension with a widening pulse pressure, bradycardia and irregular respirations is Cushing's triad, a late sign of raised intracranial pressure and possible brain herniation. Immediate emergency treatment is needed.
Answer
C · A late sign of raised intracranial pressure; an emergency
23.Mental health nursing
Answer: B · It blocks NMDA glutamate receptors
Why this is the answer
Memantine is an NMDA receptor antagonist used in moderate to severe Alzheimer's disease. It may be combined with a cholinesterase inhibitor.
Answer
B · It blocks NMDA glutamate receptors
24.Mental health nursing
Answer: A · Check the blood pressure and notify the prescriber urgently
Why this is the answer
These are signs of a hypertensive crisis. Check the blood pressure, keep her under observation and get urgent medical help. Caffeine would make it worse.
Answer
A · Check the blood pressure and notify the prescriber urgently
25.Nursing math & unit conversions
Answer: 05:00
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
5 AM → 05
Answer
05:00
Answer
05:00
26.Nursing math & unit conversions
Answer: t = 210 min
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.
Before midnight
20:40 → 24:00 = 200 min
After midnight
00:00 → 00:10 = 10 min
Total
t = 200 + 10 = 210 min
Answer
t = 210 min
27.Dosage calculations
Answer: m = 100 mg
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
5% = 5 g/100 mL = 50 mg/mL
Mass of drug
m = 50·2 = 100 mg
Answer
m = 100 mg
28.Dosage calculations
Answer: D = 95.47 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
Body surface area
BSA = √(175·75/3600) = √3.646 = 1.909 m²
Dose
D = 50·1.909 = 95.47 mg
Answer
D = 95.47 mg
29.IV infusion rates
Answer: R = 21 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
12·60 = 720 min
Drip rate
R = 250·60/720 = 20.83 ≈ 21 gtt/min
Answer
R = 21 gtt/min
At the bedside you round to the nearest whole drop: 21 gtt/min.
30.IV infusion rates
Answer: R = 30 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
4000 mg/500 mL = 8 mg/mL
Dose per hour
4·60 = 240 mg/h
Pump rate
R = 240/8 = 30 mL/h
Answer
R = 30 mL/h
31.Pediatric & critical-care dosing
Answer: D = 2 units/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
50/50 = 1 units/mL
Units per hour
D = 2·1 = 2 units/h
Answer
D = 2 units/h
32.Pediatric & critical-care dosing
Answer: D = 1.6 mcg/kg/min
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
250 000/250 = 1000 mcg/mL
Micrograms per minute
6·1000 = 6000 mcg/h
6000/60 = 100 mcg/min
Per kilogram
D = 100/62 = 1.613 ≈ 1.6 mcg/kg/min
Answer
D = 1.6 mcg/kg/min
33.IV fluids & fluid balance
Answer: U = 1.69 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
350 + 150 + 325 = 825 mL
Per kilogram per hour
U = 825/(61·8) = 1.691 ≈ 1.69 mL/kg/h
Answer
U = 1.69 mL/kg/h
34.IV fluids & fluid balance
Answer: t = 11.9 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 − 50 = 950 mL
Time
t = 950/80 = 11.88 ≈ 11.9 h
Answer
t = 11.9 h
That is about 11 h 53 min, so the bag runs out at about 17:53.
35.Clinical assessment scores
Answer: SI = 1.35
Blood pressure values: pulse pressure PP = SBP − DBP. Mean arterial pressure MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3, an estimate based on the heart spending about two thirds of each beat in diastole at a normal heart rate (less accurate when the heart rate is fast); a MAP of at least about 65 mmHg is a common target for organ perfusion. The shock index SI = heart rate/SBP is normally about 0.5–0.7; a value above about 1 is a warning sign of shock.
Shock index
SI = 104/77 = 1.351 ≈ 1.35
Answer
SI = 1.35
1 or more: a warning sign of shock in this practice case.
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: very limited → 2
moisture: rarely moist → 4
activity: walks frequently → 4
mobility: no limitation → 4
nutrition: excellent → 4
friction and shear: no apparent problem → 3
Add
Braden total = 2 + 4 + 4 + 4 + 4 + 3 = 21
Risk level
21 → not at risk
Answer
not at risk
37.Arterial blood gas interpretation
Answer: partially compensated
Reading a blood gas (ROME): first the pH: below 7.35 is acidaemia, above 7.45 alkalaemia. Then find the value that explains it. PaCO₂ (normal 35–45 mmHg, 4.7–6.0 kPa) is the respiratory part and moves Opposite to the pH in a respiratory disorder; HCO₃⁻ (normal 22–26 mmol/L) is the metabolic part and moves in the same direction as the pH (Respiratory Opposite, Metabolic Equal). The other value shows the compensation: normal means uncompensated; abnormal in the direction that pulls the pH back while the pH is still abnormal means partially compensated; a normal pH with both values abnormal means fully compensated. Ranges differ slightly between laboratories; these are practice values.
ROME, value by value
pH 7.53: alkalaemia (above 7.45)
PaCO₂ 47 mmHg: high (35–45)
HCO₃⁻ 38 mmol/L: high (22–26)
Compensation
partially compensated
Answer
partially compensated
38.Arterial blood gas interpretation
Answer: PaCO₂ = 51.1 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
0.7·43 + 21 = 51.1 mmHg
Answer
PaCO₂ = 51.1 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: sinus tachycardia
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 = 14 small boxes, 1500 ÷ 14 ≈ 107 per minute.
2. Rhythm: regular, every R–R is 0.56 s.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.12 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
sinus tachycardia
Answer
sinus tachycardia
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 0.88 s, 68 per minute); one P in every 3 is not followed by a QRS.
4. PR interval: constant at 0.18 s in the conducted beats.
5. QRS: 0.08 s, narrow (below 0.12 s).
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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