Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
Which patient goal is written in a SMART way?
AThe patient will try to eat more
BThe patient will feel better soon
CThe patient will improve mobility
DThe patient will walk 20 metres with a frame by Friday
2.Nursing fundamentalsHard
An older woman with severe arthritis has normal bladder control but wets herself because she cannot reach the toilet in time. Which type of incontinence is this?
AOverflow incontinence
BStress incontinence
CUrge incontinence
DFunctional incontinence
3.Infection control & patient safetyMedium
Why must an insulin pen never be used for more than one patient, even with a new needle?
AEach pen holds only one dose of insulin
BThe insulin in the pen would expire faster once it is shared
CSharing a pen changes the dose that is delivered
DBlood can flow back into the cartridge and spread infection
4.Infection control & patient safetyHard
Which patient most needs fall precautions?
AAn alert patient on bed rest who follows instructions
BA young adult with a broken finger who walks steadily and safely unaided
CAn older patient, newly confused, on a sedative, with an unsteady gait
DA patient awaiting discharge who walks independently
5.Prioritization & delegationMedium
Which patient should a nurse see first after report?
AA patient with osteoarthritis who reports stiffness every morning
BA patient who wants help to shower before visitors arrive
CA patient with a new cast who says the foot feels numb and the toes are cool
DA patient on a diuretic who has passed 400 mL of urine since 08:00
6.Prioritization & delegationHard
A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?
ATaking the victim straight to the X-ray department
BDecontamination before the victim enters the treatment area
CPlacing the victim in the waiting room until a doctor is free
DFull assessment inside the main department straight away
7.Clinical nursingMedium
Why is lactulose given to a patient with hepatic encephalopathy?
ATo stop bleeding from varices
BTo increase the liver's production of albumin
CTo lower the blood glucose
DTo reduce the absorption of ammonia from the gut
8.Clinical nursingHard
An older patient has fallen several times since starting a new medicine. Which drug group is most likely to contribute?
AEmollient creams applied to the legs
BLubricating eye drops
CBenzodiazepine sleeping tablets
DVitamin D supplements
9.Lab values & electrolytesMedium
In chronic kidney disease, a high serum phosphate is usually accompanied by which change in calcium?
AA high serum potassium only, with no calcium change
BNo change in calcium
CA low serum calcium
DA high serum calcium
10.Lab values & electrolytesHard
A malnourished patient starts eating again and, on day 3, has a phosphate of 1.2 mg/dL (0.39 mmol/L) with muscle weakness and shortness of breath. What is the main risk?
ARapid weight gain, but no serious danger
BHyperkalemia caused by cells releasing potassium
CKidney stones from calcium released by the bones
DWeak breathing muscles and heart failure from low phosphate
11.PharmacologyMedium
An Rh-negative mother gives birth to an Rh-positive baby. When is anti-D immunoglobulin usually given?
AIt is not needed if the baby is Rh-positive
BOnly at the start of the next pregnancy
CWithin 72 hours after the birth
DAt least two weeks after the birth
12.PharmacologyHard
A pregnant woman develops a deep vein thrombosis. Which anticoagulant is usually preferred?
AAspirin alone
BWarfarin
CLow-molecular-weight heparin, such as enoxaparin
DRivaroxaban, a direct oral factor Xa inhibitor
13.Med-surg: cardiovascular & respiratoryMedium
A patient has had atrial fibrillation for more than 48 hours and is listed for elective cardioversion. Why is anticoagulation needed beforehand?
AAnticoagulants reduce the electrical energy needed for the shock
BAnticoagulants make the shock less painful
CAnticoagulants convert AF back to sinus rhythm
DAtrial clots may be dislodged when sinus rhythm returns
14.Med-surg: cardiovascular & respiratoryHard
A patient taking dabigatran has a serious gastrointestinal bleed. Which specific reversal agent may be used?
ATranexamic acid alone
BProtamine sulfate
CIdarucizumab
DPhytomenadione (vitamin K)
15.Med-surg: neuro, endocrine & renalMedium
For which patient would the nurse question an order for pioglitazone?
AA patient with asthma
BA patient with an allergy to latex
CA patient with hypothyroidism
DA patient with heart failure
16.Med-surg: neuro, endocrine & renalHard
A 66-year-old smoker has had two episodes of painless red urine. Urine cultures are negative. Which plan is most appropriate?
AAdvise more fluids and review in a year
BAnother course of antibiotics for a UTI
CReassure him, because the blood has stopped
DUrgent referral for cystoscopy and imaging
17.Med-surg: GI, perioperative & oncologyMedium
Why is the Lund and Browder chart preferred to the rule of nines for children?
AIt adjusts for body proportions that change with age
BIt is used only for burns of the hands
CIt is faster to use than any other method of estimation
DIt counts superficial burns as well
18.Med-surg: GI, perioperative & oncologyHard
After forearm fracture surgery, a patient has severe pain not eased by opioids, made worse by passively moving the fingers. What should the nurse do?
AReassure the patient that this pain is expected
BApply ice and a tighter bandage to reduce the swelling
CRaise the arm as high as possible and give a further dose of opioid
DLoosen any tight dressing, keep the arm at heart level and escalate
19.Maternity & obstetric nursingMedium
The fetus is in the left occiput anterior position. Where is the fetal heart usually heard best?
ABelow the umbilicus on the mother's left side
BAbove the umbilicus on the mother's left side
CAbove the umbilicus on the mother's right side
DDirectly over the fundus
20.Maternity & obstetric nursingHard
A newborn has a deep dimple with a tuft of hair over the lower spine. What is the significance?
AIt means the baby will have hip dysplasia
BIt is a sign of congenital heart disease
CIt may be a sign of an underlying spinal defect
DIt is an expected birthmark with no meaning
21.Pediatric nursingMedium
A child has impetigo. Which advice helps to stop it spreading?
AUse separate towels, wash hands often and keep nails short
BPick the crusts off daily so the skin heals faster
CCover the crusts with a thick layer of petroleum jelly and leave them
DShare flannels and towels so the whole family is treated
22.Pediatric nursingHard
An 8-year-old tells the nurse that her uncle touches her in a way she does not like and asks the nurse to keep it secret. What is the best response?
AAsk detailed, leading questions to find out exactly what happened
BPhone the uncle straight away to ask for his side of the story before reporting anything
CListen calmly, praise her for telling, explain it must be shared, and follow safeguarding
DPromise to keep the secret, so that she keeps trusting the nurse and tells more later
23.Mental health nursingMedium
A patient lies awake in bed for hours worrying about not sleeping. Which stimulus control advice is correct?
ALook at the clock often to check how much sleep is being lost
BIf still awake after about 20 minutes, get up, do something calm and return when sleepy
CDo vigorous exercise in the bedroom until tired enough to fall asleep straight away
DStay in bed and watch television or use a phone until sleep finally comes
24.Mental health nursingHard
A school nurse is teaching about inhalant use such as sniffing glue or aerosols. Which risk should be stressed?
ASudden death from a heart arrhythmia, even on the first use
BInhalants are only dangerous if they are mixed with alcohol
CThere is no physical risk, because the substances are legal
DInhalants cause only a mild headache and nothing else
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 95.8 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
95.8 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). During a shift a patient takes ½ tsp of cough syrup, 3 fl oz of juice, 3 cups of tea. Using the equivalents given, find the total oral intake V in mL.
1 tsp = 5 mL1 fl oz = 30 mL1 cup = 8 fl oz = 240 mL
V = mL
27.Dosage calculationsMedium
A patient weighs 18 kg. The prescribed dose is 2 mg/kg per day, given in 3 equal doses. How many milligrams D are given per dose?
18 kg2 mg/kg/day3× per day
D = mg
28.Dosage calculationsHard
A child weighing 18 kg is prescribed 20 mg/kg per dose of an oral suspension that contains 200 mg in 5 mL. What volume V do you give?
18 kg20 mg/kg200 mg/5 mL
V = mL
29.IV infusion ratesMedium
Infuse 1500 mL over 6 hours with a giving set of 15 gtt/mL. Find the drip rate R in drops per minute. Round to the nearest whole number.
1500 mL6 h15 gtt/mL
R = gtt/min
30.IV infusion ratesHard
1000 mL was ordered over 6 hours. After 2 hours you find that 870 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?
1000 mL / 6 hafter 2 h: 870 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 18 units/kg/h for a patient who weighs 104 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
25 000 units/250 mL18 units/kg/h104 kg
R = mL/h
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A dobutamine infusion of 500 mg in 250 mL runs at 22 mL/h. The patient weighs 79 kg. What dose D in mcg/kg/min is the patient receiving? Round to one decimal place.
500 mg/250 mL22 mL/h79 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 IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
soup: 180 mLmilk: 100 mLIV infusion: 50 mL/h × 8 hIV antibiotic: 1 × 100 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 500 mL bag was started at 09:15 and runs by pump at 75 mL/h. How many mL V are left in the bag at 13:15?
500 mL75 mL/h09:15 → 13:15
V = mL
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 18/min, SpO₂ 92% on room air, blood pressure 100/60 mmHg, pulse 64/min, alert, temperature 36.4 °C. What is the NEWS2 total score?
RR 18SpO₂ 92%airSBP 100HR 64AT 36.4 °C
NEWS2 =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: yes; secondary diagnosis: yes; ambulatory aid: crutches, cane or walker; IV therapy or saline lock: yes; gait: normal, bed rest or wheelchair; mental status: overestimates or forgets limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 8 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 8 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
A practice gas shows a metabolic alkalosis with HCO₃⁻ 46 mmol/L. Use expected PaCO₂ = 0.7·HCO₃⁻ + 21 to find the expected PaCO₂.
HCO₃⁻ 46 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
1normal sinus rhythm
2junctional rhythm
3sinus tachycardia
4sinus bradycardia
40.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. Measure the P–P interval and find the atrial rate in beats per minute (1500 method, whole number).
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
atrial rate = bpm
3Solutions
1.Nursing fundamentals
Answer: D · The patient will walk 20 metres with a frame by Friday
Why this is the answer
A SMART goal states exactly what is expected, how it will be measured and by when. "Walk 20 metres with a frame by Friday" can be checked; "feel better" cannot.
Answer
D · The patient will walk 20 metres with a frame by Friday
2.Nursing fundamentals
Answer: D · Functional incontinence
Why this is the answer
Functional incontinence is caused by problems outside the urinary tract, such as poor mobility or confusion. A commode near the bed, easy clothing and regular toileting help.
Answer
D · Functional incontinence
3.Infection control & patient safety
Answer: D · Blood can flow back into the cartridge and spread infection
Why this is the answer
Blood and skin cells can be drawn back into the cartridge, so sharing a pen can transmit bloodborne infections. Each pen is labeled for a single patient.
Answer
D · Blood can flow back into the cartridge and spread infection
4.Infection control & patient safety
Answer: C · An older patient, newly confused, on a sedative, with an unsteady gait
Why this is the answer
New confusion, a sedative and an unsteady gait are major fall risk factors. The patient needs measures such as a low bed, scheduled toileting, close observation and a medication review.
Answer
C · An older patient, newly confused, on a sedative, with an unsteady gait
5.Prioritization & delegation
Answer: C · A patient with a new cast who says the foot feels numb and the toes are cool
Why this is the answer
Numbness and cool toes under a cast suggest compromised circulation, possibly compartment syndrome, which can cause permanent damage within hours. The other findings are expected or routine.
Answer
C · A patient with a new cast who says the foot feels numb and the toes are cool
6.Prioritization & delegation
Answer: B · Decontamination before the victim enters the treatment area
Why this is the answer
A stable, contaminated victim is decontaminated before entering the department, to protect staff, other patients and the victim. Life-saving care may come first only if the victim is unstable.
Answer
B · Decontamination before the victim enters the treatment area
7.Clinical nursing
Answer: D · To reduce the absorption of ammonia from the gut
Why this is the answer
Lactulose acidifies the colon and speeds transit, reducing ammonia absorption. The dose is usually adjusted to give two to three soft stools a day.
Answer
D · To reduce the absorption of ammonia from the gut
8.Clinical nursing
Answer: C · Benzodiazepine sleeping tablets
Why this is the answer
Sedatives, hypnotics, antipsychotics and drugs that lower blood pressure increase falls risk. A medication review is part of every falls assessment.
Answer
C · Benzodiazepine sleeping tablets
9.Lab values & electrolytes
Answer: C · A low serum calcium
Why this is the answer
When failing kidneys retain phosphate, phosphate binds calcium and vitamin D activation falls, so serum calcium tends to drop. This drives secondary hyperparathyroidism and bone disease.Checked against:Hypocalcemia (StatPearls) · StatPearls (NCBI Bookshelf) (2026); Phosphate in Blood · MedlinePlus (NIH) (2023)
Answer
C · A low serum calcium
10.Lab values & electrolytes
Answer: D · Weak breathing muscles and heart failure from low phosphate
Why this is the answer
When feeding restarts, insulin drives phosphate into the cells, so serum phosphate can fall sharply (refeeding syndrome). Severe hypophosphatemia weakens the diaphragm and heart. Phosphate is replaced, and feeding is increased slowly.Checked against:Refeeding Syndrome · StatPearls (NCBI Bookshelf)
Answer
D · Weak breathing muscles and heart failure from low phosphate
11.Pharmacology
Answer: C · Within 72 hours after the birth
Why this is the answer
Anti-D is given within 72 hours of birth to an Rh-negative mother of an Rh-positive baby. It is also given after events such as miscarriage or abdominal trauma, and often routinely during pregnancy.
Answer
C · Within 72 hours after the birth
12.Pharmacology
Answer: C · Low-molecular-weight heparin, such as enoxaparin
Why this is the answer
Heparins are large molecules that do not cross the placenta. Warfarin is teratogenic, and direct oral anticoagulants are not recommended in pregnancy.
Answer
C · Low-molecular-weight heparin, such as enoxaparin
13.Med-surg: cardiovascular & respiratory
Answer: D · Atrial clots may be dislodged when sinus rhythm returns
Why this is the answer
After 48 hours of AF, atrial thrombus may be present. Restoring organised contraction can expel it and cause a stroke. Patients are usually anticoagulated for at least three weeks before (or a transoesophageal echo excludes clot) and for at least four weeks afterwards.
Answer
D · Atrial clots may be dislodged when sinus rhythm returns
14.Med-surg: cardiovascular & respiratory
Answer: C · Idarucizumab
Why this is the answer
Idarucizumab binds dabigatran and reverses its effect within minutes. Andexanet alfa (or prothrombin complex concentrate where it is not available) is used for factor Xa inhibitors. Protamine reverses heparin and vitamin K reverses warfarin. Tranexamic acid may support haemostasis but is not a reversal agent.
Answer
C · Idarucizumab
15.Med-surg: neuro, endocrine & renal
Answer: D · A patient with heart failure
Why this is the answer
Pioglitazone can cause fluid retention and oedema, which can worsen heart failure. It is contraindicated in patients with heart failure. Weight gain and an increased fracture risk are other effects.
Answer
D · A patient with heart failure
16.Med-surg: neuro, endocrine & renal
Answer: D · Urgent referral for cystoscopy and imaging
Why this is the answer
Painless visible haematuria in an older smoker, with no infection, must be investigated urgently for bladder or kidney cancer. Intermittent bleeding does not mean the cause has gone.
Answer
D · Urgent referral for cystoscopy and imaging
17.Med-surg: GI, perioperative & oncology
Answer: A · It adjusts for body proportions that change with age
Why this is the answer
The Lund and Browder chart gives different percentages for the head and legs at different ages, so it is more accurate in children and is also widely used in adults.
Answer
A · It adjusts for body proportions that change with age
18.Med-surg: GI, perioperative & oncology
Answer: D · Loosen any tight dressing, keep the arm at heart level and escalate
Why this is the answer
These are early signs of compartment syndrome, where raised pressure in a muscle compartment reduces blood flow. Constrictive dressings are released, the limb is kept at heart level and urgent surgical review is needed, as fasciotomy may be required.
Answer
D · Loosen any tight dressing, keep the arm at heart level and escalate
19.Maternity & obstetric nursing
Answer: A · Below the umbilicus on the mother's left side
Why this is the answer
The fetal heart is heard most clearly through the fetal back. In a cephalic LOA position, that is in the lower left quadrant. In breech presentations, it is usually heard above the umbilicus.
Answer
A · Below the umbilicus on the mother's left side
20.Maternity & obstetric nursing
Answer: C · It may be a sign of an underlying spinal defect
Why this is the answer
A sacral dimple with a hair tuft, swelling or skin change may indicate spina bifida occulta or a tethered cord. It should be reported, and spinal ultrasound is often arranged.
Answer
C · It may be a sign of an underlying spinal defect
21.Pediatric nursing
Answer: A · Use separate towels, wash hands often and keep nails short
Why this is the answer
Impetigo spreads easily by touch. Good hand hygiene, separate towels, short nails and avoiding scratching or picking reduce spread, along with the prescribed antibiotic or antiseptic treatment.
Answer
A · Use separate towels, wash hands often and keep nails short
22.Pediatric nursing
Answer: C · Listen calmly, praise her for telling, explain it must be shared, and follow safeguarding
Why this is the answer
The nurse listens without showing shock, reassures the child, avoids leading questions, records her words accurately and explains that people who can help need to know. The concern is reported at once through the safeguarding procedure.
Answer
C · Listen calmly, praise her for telling, explain it must be shared, and follow safeguarding
23.Mental health nursing
Answer: B · If still awake after about 20 minutes, get up, do something calm and return when sleepy
Why this is the answer
Stimulus control strengthens the bed as a cue for sleep. Getting up when unable to sleep, using the bed only for sleep and intimacy, and keeping a regular wake time are key parts.
Answer
B · If still awake after about 20 minutes, get up, do something calm and return when sleepy
24.Mental health nursing
Answer: A · Sudden death from a heart arrhythmia, even on the first use
Why this is the answer
Inhalants can sensitise the heart to adrenaline and cause fatal arrhythmias ("sudden sniffing death"), even in first-time users. They can also cause suffocation and brain, liver and kidney damage.
Answer
A · Sudden death from a heart arrhythmia, even on the first use
25.Nursing math & unit conversions
Answer: T = 35.4 °C
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Subtract 32
95.8 − 32 = 63.8
Multiply by 5/9
T = 63.8·5/9 = 35.44 ≈ 35.4 °C
Answer
T = 35.4 °C
26.Nursing math & unit conversions
Answer: V = 812.5 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
½ tsp = 0.5·5 = 2.5 mL
3 fl oz = 3·30 = 90 mL
3 cups = 3·240 = 720 mL
Add
V = 2.5 + 90 + 720 = 812.5 mL
Answer
V = 812.5 mL
27.Dosage calculations
Answer: D = 12 mg
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Total per day
2·18 = 36 mg
Per dose
D = 36/3 = 12 mg
Answer
D = 12 mg
28.Dosage calculations
Answer: V = 9 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
20·18 = 360 mg
Volume
V = (360/200)·5 = 9 mL
Answer
V = 9 mL
29.IV infusion rates
Answer: R = 63 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 = 1500·15/360 = 62.5 ≈ 63 gtt/min
Answer
R = 63 gtt/min
At the bedside you round to the nearest whole drop: 63 gtt/min.
30.IV infusion rates
Answer: Δ = 30.5 %
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
1000/6 = 166.7 mL/h
New rate
R = 870/4 = 217.5 mL/h
Percentage change
Δ = (217.5 − 166.7)/166.7·100% = 30.5%
Answer
Δ = 30.5%
This is more than a 25% increase: most hospitals require you to contact the prescriber instead of catching up, and to assess the patient for fluid overload.
31.Pediatric & critical-care dosing
Answer: R = 18.7 mL/h
Heparin and insulin infusions: concentration = units in the bag/bag volume (units/mL). Pump rate (mL/h) = units per hour/concentration, and units per hour = mL/h × concentration. For a weight-based order, units/h = units/kg/h × weight first. A bolus volume = units needed/vial strength. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Units per hour
18·104 = 1 872 units/h
Concentration
25 000/250 = 100 units/mL
Pump rate
R = 1872/100 = 18.72 ≈ 18.7 mL/h
Answer
R = 18.7 mL/h
32.Pediatric & critical-care dosing
Answer: D = 9.3 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
500 000/250 = 2000 mcg/mL
Micrograms per minute
22·2000 = 44000 mcg/h
44000/60 = 733.3 mcg/min
Per kilogram
D = 733.3/79 = 9.283 ≈ 9.3 mcg/kg/min
Answer
D = 9.3 mcg/kg/min
33.IV fluids & fluid balance
Answer: I = 780 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.
Add the intake
oral: 180 + 100 = 280 mL
IV infusion: 50·8 = 400 mL
IV antibiotic: 1·100 = 100 mL
I = 780 mL
Answer
I = 780 mL
34.IV fluids & fluid balance
Answer: V = 200 mL
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Elapsed time
09:15 → 13:15 = 4 h
Volume infused
75·4 = 300 mL
Volume left
V = 500 − 300 = 200 mL
Answer
V = 200 mL
35.Clinical assessment scores
Answer: NEWS2 = 4
NEWS2 (National Early Warning Score 2, Royal College of Physicians 2017): score each of the seven parameters with the chart (respiration rate, SpO₂ on scale 1, air or supplemental oxygen, systolic blood pressure, pulse, consciousness on the ACVPU scale and temperature) and add the scores. Clinical risk: 0–4 low; a score of 3 in any single parameter low–medium; 5–6 medium; 7 or more high. A total of 5 or more needs an urgent response.
Score each parameter
RR 18/min → 0
SpO₂ 92% → 2
on air → 0
SBP 100 mmHg → 2
HR 64/min → 0
alert (A) → 0
T 36.4 °C → 0
Add
NEWS2 = 0 + 2 + 0 + 2 + 0 + 0 + 0 = 4
Answer
NEWS2 = 4
36.Clinical assessment scores
Answer: high risk
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: yes → 25
secondary diagnosis: yes → 15
ambulatory aid: crutches, cane or walker → 15
IV therapy or saline lock: yes → 20
gait: normal, bed rest or wheelchair → 0
mental status: overestimates or forgets limits → 15
Add
Morse total = 25 + 15 + 15 + 20 + 0 + 15 = 90
Risk level
90 → high risk
Answer
high risk
37.Arterial blood gas interpretation
Answer: PaCO₂ = 20 mmHg
Expected compensation: in metabolic acidosis Winter’s formula predicts PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg; a measured value above that range points to an additional respiratory acidosis, below it to an additional respiratory alkalosis. The anion gap AG = Na⁺ − (Cl⁻ + HCO₃⁻), normally about 8–12 mmol/L, separates high-gap from normal-gap metabolic acidosis; low albumin hides a high gap (add 2.5 per g/dL that albumin is below 4.0). The delta ratio (AG − 12)/(24 − HCO₃⁻) between about 0.8 and 2 fits a pure high-gap acidosis (some texts use 1 instead of 0.8), below that an added normal-gap acidosis, and above 2 an added metabolic alkalosis.
Winter’s formula
PaCO₂ = 1.5·8 + 8 = 20 mmHg
range: 18–22 mmHg
Answer
PaCO₂ = 20 mmHg
38.Arterial blood gas interpretation
Answer: PaCO₂ = 53.2 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
0.7·46 + 21 = 53.2 mmHg
Answer
PaCO₂ = 53.2 mmHg
The rise has a limit: PaCO₂ rarely goes above about 55 mmHg from compensation alone.
39.ECG rhythm strip interpretation
Answer: normal sinus rhythm
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 = 18 small boxes, 1500 ÷ 18 ≈ 83 per minute.
2. Rhythm: regular, every R–R is 0.72 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
normal sinus rhythm
Answer
normal sinus rhythm
40.ECG rhythm strip interpretation
Answer: atrial rate = 68 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 = 22 small boxes = 0.88 s → 1500 ÷ 22 = 68.18 ≈ 68 per minute
Ventricular rate
6 QRS complexes in 6 s × 10 = 60 per minute
Answer
atrial rate = 68 bpm
Answer
atrial rate = 68 bpm
Second-degree type II: 4 P waves for every 3 QRS complexes, with a constant PR.
This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.