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 does the Malnutrition Universal Screening Tool (MUST) assess?
AThe risk of falling
BThe level of pain
CThe risk of malnutrition
DSwallowing ability
2.Nursing fundamentalsHard
A patient who had a GCS of 15 this morning now opens their eyes only to voice and is confused. What should the nurse do?
ARecord it and recheck at the next routine time
BTreat it as deterioration and escalate urgently
CLet the patient sleep, as they are probably tired
DGive a sedative to calm the confusion
3.Infection control & patient safetyMedium
A patient is admitted to an inpatient mental health unit. Why are personal belongings checked?
ATo remove items that could be used to harm self or others
BTo make a list of valuable items for insurance
CTo find out what the patient likes to wear during the hospital stay
DTo decide which family members may visit
4.Infection control & patient safetyHard
A patient with pulmonary tuberculosis has been on treatment. Which findings usually allow airborne isolation to end?
AThe patient has been in hospital for one week and has taken every dose of medicine
BThe cough has stopped, even with no sputum tests
COne negative chest x-ray after starting treatment
DThree negative sputum smears, clinical improvement and continued therapy
5.Prioritization & delegationMedium
A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?
A“I will tell the nurse if she becomes very sleepy or hard to wake.”
B“I will press the button for her while she is asleep so she stays comfortable.”
C“The pump has limits set by the nurse so she cannot get too much at once.”
D“Only she should press the button when she needs pain relief.”
6.Prioritization & delegationHard
A patient with a head injury has a pupil on one side that is now large and does not react to light. What should the nurse do?
ADocument it, because pupils often differ slightly after a head injury
BReport it at once, as it may mean the brain is being compressed
CDim the room lights so the pupil can get smaller
DRecheck it at the next routine observation in four hours
7.Clinical nursingMedium
Which blood results are typical of Addison's disease (primary adrenal insufficiency)?
AHigh glucose and high calcium
BLow haemoglobin and high platelets
CLow sodium and high potassium
DHigh sodium and low potassium
8.Clinical nursingHard
Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?
AEnteral syringes keep the medicine sterile
BIV syringes cannot hold liquid medicines
CTo prevent accidental intravenous administration
DEnteral syringes measure doses less accurately
9.Lab values & electrolytesMedium
A patient has started parenteral nutrition (PN) through a central line. Which test is monitored most frequently in the first days?
ABlood glucose
BHemoglobin A1c
CThyroid hormones
DSerum lipase
10.Lab values & electrolytesHard
During an IV magnesium sulfate infusion, which assessment best detects toxicity early?
ASkin color and capillary refill every hour
BKnee reflexes, respiratory rate and urine output
CBowel sounds and abdominal girth
DBlood glucose and pupil size every hour
11.PharmacologyMedium
How does heparin produce its anticoagulant effect?
AIt breaks down fibrin in existing clots
BIt irreversibly inhibits platelet COX-1
CIt blocks the vitamin K-dependent synthesis of clotting factors in the liver
DIt enhances antithrombin, which inactivates thrombin and factor Xa
12.PharmacologyHard
What is the main mechanism of action of proton pump inhibitors such as omeprazole?
ACoating the ulcer to protect it
BIrreversible inhibition of the H⁺/K⁺-ATPase in parietal cells
CCompetitive blocking of histamine H2 receptors on parietal cells
DNeutralising acid in the stomach
13.Med-surg: cardiovascular & respiratoryMedium
A woman with hypertension who takes lisinopril says she is planning a pregnancy. What should the nurse advise?
ADouble the dose to protect the baby from high blood pressure
BDiscuss switching medicine with the prescriber before trying to conceive
CStop all blood pressure treatment straight away without telling anyone
DContinue lisinopril, as it is the safest blood pressure drug in pregnancy
14.Med-surg: cardiovascular & respiratoryHard
A ventilated patient in critical care is at risk of ventilator-associated pneumonia. Which nursing measure helps reduce this risk?
AAvoiding mouth care to prevent gum bleeding
BKeeping the patient flat to protect the endotracheal tube
CChanging the ventilator tubing every few hours
DKeeping the head of the bed raised to 30–45°
15.Med-surg: neuro, endocrine & renalMedium
Why is intermittent self-catheterisation often taught after a spinal cord injury?
AThe bladder may not empty, and regular emptying protects the kidneys
BIt removes all risk of a urinary tract infection completely
CIt is mainly used to measure the urine output accurately
DIt trains the bladder to grow gradually larger over time
16.Med-surg: neuro, endocrine & renalHard
A patient with suspected meningitis has a GCS of 9 and pupils that have become unequal. A doctor plans an immediate lumbar puncture. What is the main concern?
AThere is no concern, because the lumbar puncture lowers pressure safely
BA lumbar puncture would spread the infection to the blood
CRaised pressure in the skull, so the procedure could cause herniation
DThe patient is too confused to stay still, so it is not needed
17.Med-surg: GI, perioperative & oncologyMedium
Which advice is appropriate for a patient with a very low platelet count?
ATake aspirin regularly for headaches
BUse a soft toothbrush and an electric razor
CUse a razor blade for shaving every day
DFloss hard every day to prevent gum disease
18.Med-surg: GI, perioperative & oncologyHard
A patient on a long-term opioid for chronic pain is admitted for surgery. Which statement is correct?
AThe usual opioid is continued, plus extra analgesia, due to tolerance
BThey need lower postoperative opioid doses than opioid-naive patients
CThey should receive only paracetamol after the operation is over
DAll opioids should be stopped on admission to prevent addiction
19.Maternity & obstetric nursingMedium
Which antihypertensive is commonly used in pregnancy but should be avoided in a woman with asthma?
ALabetalol
BHydralazine
CMethyldopa
DNifedipine
20.Maternity & obstetric nursingHard
A woman with a placenta praevia at 35 weeks is waiting for a planned caesarean. Which activity should she avoid?
ALying on her side
BSexual intercourse
CGentle walking
DEating a normal diet
21.Pediatric nursingMedium
Which temperature is usually taken as fever in a child?
A38.0 °C (100.4 °F) or higher
B39.5 °C (103.1 °F) or higher
C37.0 °C (98.6 °F) or higher
D37.5 °C (99.5 °F) or higher
22.Pediatric nursingHard
How is pain best assessed in a 10-year-old with severe cerebral palsy who cannot speak?
AWith a 0–10 numerical scale, by asking the child to point to a number on a printed chart
BWith a behavioural tool such as revised FLACC, using the parents' knowledge of usual cues
CPain cannot be assessed, so analgesia is given only on request
DOnly by checking whether the heart rate is above normal
23.Mental health nursingMedium
An 80-year-old man often talks about his life and his achievements. According to Erikson, which task is he working on?
AIntimacy versus isolation
BGenerativity versus stagnation
CIdentity versus role confusion
DIntegrity versus despair
24.Mental health nursingHard
A patient with somatic symptom disorder calls the nurse many times each shift to report different aches. Which approach is most helpful?
ATell her that her symptoms are all in her mind, so there is no need to assess them or treat them in any way
BAsk the doctor to order new tests every time she reports a symptom
CStop answering her calls, because the symptoms are imaginary
DArrange regular, planned contacts, assess any new symptoms and focus conversations on feelings and coping
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient is 5 ft 5 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 5 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 1 tbsp of an oral suspension twice a day for 14 days. The suspension comes in 100 mL bottles. Using 1 tbsp = 15 mL, how many whole bottles N must be supplied so the course is complete?
1 tbsptwice a day14 days100 mL1 tbsp = 15 mL
N =
27.Dosage calculationsMedium
A patient weighing 60 kg has a body surface area of 1.5 m². The prescription is 250 mg/m². Find the dose D in mg.
60 kgBSA = 1.5 m²250 mg/m²
D = mg
28.Dosage calculationsHard
A child weighing 18 kg is prescribed 15 mg/kg per dose of an oral suspension that contains 40 mg in 1 mL. What volume V do you give? Round to one decimal place.
18 kg15 mg/kg40 mg/1 mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 6 hours with a giving set of 20 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1500 mL6 h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
A drip runs at 25 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?
25 gtt/min20 gtt/mL750 mL
t = h
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 14 units/kg/h for a patient who weighs 57 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL14 units/kg/h57 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dopamine infusion of 400 mg in 250 mL runs at 33 mL/h. The patient weighs 61 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
400 mg/250 mL33 mL/h61 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 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 500 mL bag runs by pump at 80 mL/h. At 18:00, 300 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
500 mL300 mL infused80 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: occasionally moist; activity: bedfast; mobility: no limitation; nutrition: very poor; friction and shear: problem. Find the Braden total B.
6–23
B =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). An adult weighs 148 kg and is 166 cm tall. Calculate the BMI and click the WHO weight category.
148 kg166 cm
1underweight
2healthy weight
3overweight
4obesity class I
5obesity class II
6obesity class III
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.42, PaCO₂ 29 mmHg (3.9 kPa) and HCO₃⁻ 18 mmol/L. The primary disorder is respiratory alkalosis. How far is it compensated? Click your answer.
pH 7.42PaCO₂ 29 mmHg (3.9 kPa)HCO₃⁻ 18 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic acidosis: pH 7.27, PaCO₂ 25 mmHg (3.3 kPa), HCO₃⁻ 11 mmol/L. Compare the measured PaCO₂ with Winter’s formula. Click your interpretation.
pH 7.27PaCO₂ 25 mmHg (3.3 kPa)HCO₃⁻ 11 mmol/L
1appropriate compensation
2added respiratory acidosis
3added respiratory alkalosis
39.ECG rhythm strip interpretationMedium
Measure the QT interval on this lead II strip, in seconds.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
QT = s
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block with an irregular ventricular rhythm. Use the 6-second method to find the ventricular rate in beats per minute.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
ventricular rate = bpm
3Solutions
1.Nursing fundamentals
Answer: C · The risk of malnutrition
Why this is the answer
MUST combines body mass index, unplanned weight loss and acute disease effect into a score that shows the risk of malnutrition and guides nutritional care.
Answer
C · The risk of malnutrition
2.Nursing fundamentals
Answer: B · Treat it as deterioration and escalate urgently
Why this is the answer
The score has dropped to about 13. Any new fall in consciousness or new confusion needs urgent escalation, a full ABCDE assessment and a check of glucose.
Answer
B · Treat it as deterioration and escalate urgently
3.Infection control & patient safety
Answer: A · To remove items that could be used to harm self or others
Why this is the answer
Belongings are searched with the patient, according to policy, for items such as sharp objects, cords, drugs and lighters. These are stored safely to reduce the risk of self-harm or violence.
Answer
A · To remove items that could be used to harm self or others
4.Infection control & patient safety
Answer: D · Three negative sputum smears, clinical improvement and continued therapy
Why this is the answer
Airborne precautions usually continue until the patient is on effective therapy, is improving clinically and has three negative sputum smears for acid-fast bacilli, according to policy.
Answer
D · Three negative sputum smears, clinical improvement and continued therapy
5.Prioritization & delegation
Answer: B · “I will press the button for her while she is asleep so she stays comfortable.”
Why this is the answer
PCA is safe because a sleepy patient cannot press the button. If someone else presses it, the patient can receive too much opioid and develop respiratory depression.
Answer
B · “I will press the button for her while she is asleep so she stays comfortable.”
6.Prioritization & delegation
Answer: B · Report it at once, as it may mean the brain is being compressed
Why this is the answer
A newly fixed, dilated pupil suggests pressure on the third cranial nerve from rising intracranial pressure or a bleed. It is a neurological emergency that needs immediate escalation.
Answer
B · Report it at once, as it may mean the brain is being compressed
7.Clinical nursing
Answer: C · Low sodium and high potassium
Why this is the answer
Without aldosterone, the kidneys lose sodium and retain potassium. Patients may also have low blood pressure, low glucose and increased skin pigmentation.
Answer
C · Low sodium and high potassium
8.Clinical nursing
Answer: C · 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
C · To prevent accidental intravenous administration
9.Lab values & electrolytes
Answer: A · Blood glucose
Why this is the answer
PN contains concentrated dextrose, so hyperglycemia is common, especially at the start; glucose is checked frequently and insulin may be needed. Electrolytes, including phosphate, magnesium and potassium, are also monitored for refeeding syndrome.
Answer
A · Blood glucose
10.Lab values & electrolytes
Answer: B · Knee reflexes, respiratory rate and urine output
Why this is the answer
Loss of the knee reflex is an early warning sign of magnesium toxicity and appears before slowed breathing. Magnesium is cleared by the kidneys, so falling urine output increases the risk. IV calcium gluconate counteracts magnesium toxicity.Checked against:Magnesium Toxicity · StatPearls (NCBI Bookshelf) (2026); Magnesium Toxicity · StatPearls (NCBI Bookshelf)
Answer
B · Knee reflexes, respiratory rate and urine output
11.Pharmacology
Answer: D · It enhances antithrombin, which inactivates thrombin and factor Xa
Why this is the answer
Heparin binds antithrombin and greatly accelerates its inactivation of thrombin and factor Xa. Low-molecular-weight heparins act mainly on factor Xa.
Answer
D · It enhances antithrombin, which inactivates thrombin and factor Xa
12.Pharmacology
Answer: B · Irreversible inhibition of the H⁺/K⁺-ATPase in parietal cells
Why this is the answer
PPIs irreversibly block the proton pump, the last step of acid secretion. H2 blockers (such as famotidine) act earlier and are less powerful; antacids only neutralise.
Answer
B · Irreversible inhibition of the H⁺/K⁺-ATPase in parietal cells
13.Med-surg: cardiovascular & respiratory
Answer: B · Discuss switching medicine with the prescriber before trying to conceive
Why this is the answer
ACE inhibitors and ARBs are contraindicated in pregnancy because they can damage fetal kidneys and cause other harm. Women of childbearing age should be counselled and switched to a suitable alternative, such as labetalol or nifedipine, before conception or as soon as pregnancy is confirmed.
Answer
B · Discuss switching medicine with the prescriber before trying to conceive
14.Med-surg: cardiovascular & respiratory
Answer: D · Keeping the head of the bed raised to 30–45°
Why this is the answer
Ventilator care bundles include head elevation of 30–45°, regular oral care, daily assessment of readiness to wean (sedation holds) and subglottic secretion drainage where available. Frequent circuit changes are not recommended unless the tubing is soiled or faulty.
Answer
D · Keeping the head of the bed raised to 30–45°
15.Med-surg: neuro, endocrine & renal
Answer: A · The bladder may not empty, and regular emptying protects the kidneys
Why this is the answer
Spinal cord injury often causes neurogenic bladder. Clean intermittent catheterisation at regular intervals empties the bladder, prevents high pressures, reduces infection and kidney damage and avoids triggering autonomic dysreflexia.
Answer
A · The bladder may not empty, and regular emptying protects the kidneys
16.Med-surg: neuro, endocrine & renal
Answer: C · Raised pressure in the skull, so the procedure could cause herniation
Why this is the answer
Reduced consciousness and unequal pupils suggest raised ICP. A lumbar puncture in this situation may cause brain herniation, so imaging comes first, and antibiotics are not delayed. The nurse should raise this concern.
Answer
C · Raised pressure in the skull, so the procedure could cause herniation
17.Med-surg: GI, perioperative & oncology
Answer: B · Use a soft toothbrush and an electric razor
Why this is the answer
With thrombocytopenia, the nurse reduces bleeding risk: soft toothbrush, electric razor, no NSAIDs or aspirin, avoiding IM injections and rectal procedures, and reporting bleeding, bruising or blood in urine or stool.
Answer
B · Use a soft toothbrush and an electric razor
18.Med-surg: GI, perioperative & oncology
Answer: A · The usual opioid is continued, plus extra analgesia, due to tolerance
Why this is the answer
Patients on long-term opioids have tolerance and physical dependence. Stopping their usual opioid risks withdrawal and uncontrolled pain. Their baseline dose is continued (or converted to another route) and multimodal analgesia added; they often need more opioid than opioid-naive patients, with careful monitoring.
Answer
A · The usual opioid is continued, plus extra analgesia, due to tolerance
19.Maternity & obstetric nursing
Answer: A · Labetalol
Why this is the answer
Labetalol is a beta and alpha blocker and can cause bronchospasm, so it is avoided in asthma. Nifedipine, a calcium channel blocker, is often used instead.
Answer
A · Labetalol
20.Maternity & obstetric nursing
Answer: B · Sexual intercourse
Why this is the answer
Women with placenta praevia are advised to avoid intercourse and anything inserted into the vagina because it may cause bleeding. They should report any bleeding or contractions straight away.
Answer
B · Sexual intercourse
21.Pediatric nursing
Answer: A · 38.0 °C (100.4 °F) or higher
Why this is the answer
A temperature of 38.0 °C (100.4 °F) or higher is generally considered a fever in children. In young infants even a modest fever can signal serious infection and needs prompt assessment.
Answer
A · 38.0 °C (100.4 °F) or higher
22.Pediatric nursing
Answer: B · With a behavioural tool such as revised FLACC, using the parents' knowledge of usual cues
Why this is the answer
Children with cognitive impairment are assessed with behavioural tools such as the revised FLACC, which can include the child's individual pain behaviours. Parents know the child's baseline and are key partners in pain assessment.
Answer
B · With a behavioural tool such as revised FLACC, using the parents' knowledge of usual cues
23.Mental health nursing
Answer: D · Integrity versus despair
Why this is the answer
In later life, the task is to look back and find meaning in one's life. Reminiscence supports a sense of integrity; failure leads to regret and despair.
Answer
D · Integrity versus despair
24.Mental health nursing
Answer: D · Arrange regular, planned contacts, assess any new symptoms and focus conversations on feelings and coping
Why this is the answer
Scheduled contact reduces the need to report symptoms to get attention. New symptoms must still be assessed, because physical illness can occur, but the focus shifts towards stress, feelings and coping skills.
Answer
D · Arrange regular, planned contacts, assess any new symptoms and focus conversations on feelings and coping
25.Nursing math & unit conversions
Answer: h = 165 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 + 5 = 65 in
Inches to centimetres
h = 65·2.54 = 165.1 ≈ 165 cm
Answer
h = 165 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
15 mL × 2 × 14 = 420 mL
Bottles
420/100 = 4.2 → N = 5
Answer
N = 5
27.Dosage calculations
Answer: D = 375 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).
Dose
D = 250·1.5 = 375 mg
Answer
D = 375 mg
28.Dosage calculations
Answer: V = 6.8 mL
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 from weight
15·18 = 270 mg
Volume
V = (270/40)·1 = 6.75 ≈ 6.8 mL
Answer
V = 6.8 mL
29.IV infusion rates
Answer: R = 83 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
6·60 = 360 min
Drip rate
R = 1500·20/360 = 83.33 ≈ 83 gtt/min
Answer
R = 83 gtt/min
At the bedside you round to the nearest whole drop: 83 gtt/min.
30.IV infusion rates
Answer: t = 10 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
25·60/20 = 75 mL/h
Time left
t = 750/75 = 10 h
Answer
t = 10 h
31.Pediatric & critical-care dosing
Answer: R = 8 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
14·57 = 798 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 798/100 = 7.98 ≈ 8 mL/h
Answer
R = 8 mL/h
32.Pediatric & critical-care dosing
Answer: D = 14.4 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
400 000/250 = 1600 mcg/mL
Micrograms per minute
33·1600 = 52800 mcg/h
52800/60 = 880 mcg/min
Per kilogram
D = 880/61 = 14.43 ≈ 14.4 mcg/kg/min
Answer
D = 14.4 mcg/kg/min
33.IV fluids & fluid balance
Answer: B = −650 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: 200 + 250 = 450 mL
IV infusion: 50·12 = 600 mL
IV antibiotic: 2·50 = 100 mL
total intake = 1150 mL
Total output
475 + 375 + 350 + 500 + 100 = 1800 mL
Balance
B = 1150 − 1800 = −650 mL
Answer
B = −650 mL
Negative: the patient lost more fluid than went in.
34.IV fluids & fluid balance
Answer: t = 2.5 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
500 − 300 = 200 mL
Time
t = 200/80 = 2.5 h
Answer
t = 2.5 h
That is about 2 h 30 min, so the bag runs out at about 20:30.
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: occasionally moist → 3
activity: bedfast → 1
mobility: no limitation → 4
nutrition: very poor → 1
friction and shear: problem → 1
Add
Braden total = 1 + 3 + 1 + 4 + 1 + 1 = 11
Answer
B = 11
36.Clinical assessment scores
Answer: obesity class III
Body mass index: BMI = weight (kg)/height (m)², with the height converted to metres first. With pounds and inches, BMI = 703 × weight (lb)/height (in)². WHO adult categories: below 18.5 underweight, 18.5–24.9 healthy weight, 25.0–29.9 overweight, 30.0–34.9 obesity class I, 35.0–39.9 obesity class II and 40 or more obesity class III.
BMI
BMI = 148/1.66² = 53.71
Category
obesity class III
Answer
obesity class III
37.Arterial blood gas interpretation
Answer: fully 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 7.42: within 7.35–7.45
PaCO₂ 29 mmHg: low (35–45)
HCO₃⁻ 18 mmol/L: low (22–26)
Compensation
fully compensated
Answer
fully compensated
38.Arterial blood gas interpretation
Answer: appropriate compensation
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Expected PaCO₂
1.5·11 + 8 = 24.5 → 22.5–26.5 mmHg
Compare
measured: 25 mmHg → appropriate compensation
Answer
appropriate compensation
39.ECG rhythm strip interpretation
Answer: QT = 0.48 s
QT and QTc: the QT interval runs from the start of the QRS complex to the end of the T wave. It shortens as the heart rate rises, so it is corrected for rate with the R–R interval in seconds: Bazett QTc = QT/√RR and Fridericia QTc = QT/∛RR. Bazett is the formula most textbooks use; it over-corrects at fast rates, where Fridericia is preferred. Limits differ between references: a QTc above about 0.45 s in men or 0.46 s in women is usually called prolonged, and above 0.50 s markedly prolonged.
Measure
12 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 12 × 0.04 s = 0.48 s
Answer
QT = 0.48 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 0.84 s).
40.ECG rhythm strip interpretation
Answer: ventricular rate = 40 bpm
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.
Atrial rate
P–P = 24 small boxes = 0.96 s → 1500 ÷ 24 = 62.5 ≈ 63 per minute
Ventricular rate
4 QRS complexes in 6 s × 10 = 40 per minute
Answer
ventricular rate = 40 bpm
Answer
ventricular rate = 40 bpm
Second-degree type I (Wenckebach): 3 P waves for every 2 QRS complexes.
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