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
How should a rectal suppository be inserted?
AJust inside the anus, without passing the sphincter
BAfter the patient has stood up and bent forward
CPast the internal sphincter, against the rectal wall
DInto the middle of the stool in the rectum so it softens it
2.Nursing fundamentalsHard
A nurse notices that the power cable of an infusion pump is frayed. What is the correct action?
AUnplug it and put it back in the equipment store
BUse it only for patients who are not seriously ill
CTake it out of use, label it as faulty and report it
DWrap tape around the cable and keep using it
3.Infection control & patient safetyMedium
Many intensive care units bathe patients daily with chlorhexidine. What is the main purpose?
ATo lower the patient’s body temperature
BTo moisturize dry skin in older patients
CTo reduce skin bacteria and bloodstream infections linked to central lines
DTo treat existing wound infections without the need for antibiotics
4.Infection control & patient safetyHard
Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?
ARespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38.5 °C
BRespiratory rate 24/min, new confusion, systolic BP 95 mmHg
CRespiratory rate 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm3
Using the Emergency Severity Index, which patient receives the highest acuity level?
AA patient with chest pain and normal vital signs
BAn unresponsive patient with gasping, irregular breaths
CA patient with a possible ankle fracture
DA patient with a sore throat for three days and normal vital signs
6.Prioritization & delegationHard
An RN has five patients and a nursing assistant. One patient has just become short of breath. Which task should the RN delegate so that the RN can go to that patient?
AMorning vital signs on the four stable patients
BAssessing the breathless patient’s lung sounds
CGiving the breathless patient’s IV furosemide
DExplaining the new diagnosis to the breathless patient’s family
7.Clinical nursingMedium
Which side effect of regular opioids usually needs preventive treatment from the start?
AHigh blood pressure
BConstipation
CExcessive hunger
DDiarrhoea
8.Clinical nursingHard
A patient is recognised by the team as being in the last days of life. Which approach is correct?
AStop all medicines, including pain relief and anti-sickness drugs
BReview and stop treatments that no longer help, and focus on comfort
CContinue all routine blood tests and observations four-hourly
DAvoid talking with the family about what is happening
9.Lab values & electrolytesMedium
When should the nurse check the glucose before giving a mealtime dose of rapid-acting insulin (such as lispro)?
AAt bedtime only, then giving the mealtime insulin overnight
BJust before the meal, giving insulin when the food is ready
COnly once a day, then giving the same dose before every meal
DTwo hours after the meal, then giving the insulin dose
10.Lab values & electrolytesHard
A patient with heart failure takes lisinopril, spironolactone and a potassium supplement. Today the potassium is 6.0 mEq/L. What is the most likely explanation?
ALisinopril lowers potassium
BSpironolactone causes potassium loss
CSeveral medicines that raise potassium are being taken together
DPotassium supplements have no effect on the serum level
11.PharmacologyMedium
Which lab tests are monitored in a patient taking carbamazepine?
ASerum amylase and lipase
BFull blood count and serum sodium
CINR and aPTT
DThyroid antibodies and cortisol
12.PharmacologyHard
A 19-year-old woman is starting isotretinoin for severe acne. Which requirement is most important?
AWeekly hearing tests and monthly eye examinations during treatment
BA high-vitamin A diet to boost the effect
CTaking the drug only at weekends
DReliable contraception and pregnancy tests, as it is highly teratogenic
13.Med-surg: cardiovascular & respiratoryMedium
A woman with hypertension who takes lisinopril says she is planning a pregnancy. What should the nurse advise?
AStop all blood pressure treatment straight away without telling anyone
BContinue lisinopril, as it is the safest blood pressure drug in pregnancy
CDiscuss switching medicine with the prescriber before trying to conceive
DDouble the dose to protect the baby from high blood pressure
14.Med-surg: cardiovascular & respiratoryHard
A patient with an inferior myocardial infarction develops complete heart block with a heart rate of 38/min. What is the most likely reason?
AHeart block is caused by the thrombolytic drug
BThe left anterior descending artery supplies the SA node only
CInferior infarcts always destroy the bundle of His permanently
DThe right coronary artery usually supplies the AV node
15.Med-surg: neuro, endocrine & renalMedium
A patient with multiple sclerosis says their symptoms get worse after a hot bath. What should the nurse explain?
AThey should take very cold baths to reverse the damage
BThis shows that the disease has entered a new progressive stage
CHot baths cause new areas of damage in the brain
DHeat can briefly worsen MS symptoms, which settle when they cool down
16.Med-surg: neuro, endocrine & renalHard
Near the end of a haemodialysis session, a patient has painful leg cramps and a falling blood pressure. What is the most likely cause?
AFluid is being removed too quickly
BAn allergic reaction to the needles
CThe dialysate is too cold
DNot enough fluid is being removed
17.Med-surg: GI, perioperative & oncologyMedium
Why might a patient's platelet count be monitored while they receive heparin?
ATo check whether the heparin is causing anaemia
BTo measure the heparin dose in the blood exactly
CTo detect heparin-induced thrombocytopenia
DTo see whether the patient has an infection
18.Med-surg: GI, perioperative & oncologyHard
A patient with cirrhosis and ascites has a falling urine output and a rising creatinine. They have not received nephrotoxic drugs and are not dehydrated. Which complication is likely?
ANephrotic syndrome
BUrinary tract infection
CPolycystic kidney disease
DHepatorenal syndrome
19.Maternity & obstetric nursingMedium
Which finding is a contraindication to a fetal scalp electrode?
AMaternal HIV infection
BMembranes that have ruptured
CCervical dilation of 4 cm
DA cephalic presentation
20.Maternity & obstetric nursingHard
A woman at 34 weeks with type 1 diabetes has a blood glucose of 2.8 mmol/L (50 mg/dL), is sweating and shaky but is alert. What should the nurse do first?
AGive fast-acting glucose by mouth and recheck
BCheck the fetal heart rate before any treatment
CGive her usual insulin dose
DWait until her next meal
21.Pediatric nursingMedium
Which instruction about giving oral liquid iron to a child is correct?
AGive it with a syringe or straw towards the back of the mouth; dark stools are expected
BStop the iron straight away if the stools turn dark green or black, as this means bleeding
CGive it mixed in a full bottle of milk to reduce stomach upset
DGive it together with an antacid to protect the stomach
22.Pediatric nursingHard
A 9-year-old is being treated for an acute asthma attack. Which finding shows that treatment is working?
AThe child is now sitting bolt upright, leaning on the arms
BSlower breathing, easier speech and less use of the neck and chest muscles
CThe wheeze has disappeared and the child is now very drowsy
DThe heart rate has risen further after each dose of salbutamol
23.Mental health nursingMedium
A patient with schizophrenia says, "The voices are telling me I'm evil." Which response is best?
A"Let's not talk about the voices for now. Tell me about your family and your plans instead."
B"I don't hear the voices, but I can see they are upsetting you. What are they saying to you?"
C"The voices aren't real, so just ignore them."
D"If you hear voices, you must be very ill."
24.Mental health nursingHard
A 76-year-old with no history of mental illness suddenly develops paranoid ideas and hallucinations. What is the most appropriate first step?
ADiagnose late-onset schizophrenia and start an antipsychotic immediately
BAdmit him to a secure psychiatric ward straight away, without any physical examination or blood tests
CAssume it is normal ageing and take no action
DLook for medical causes, such as delirium, medicines, infection or a neurocognitive disorder
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.87899 mL. The rule in this exercise is that volumes below 1 mL are rounded to the nearest hundredth of a mL. What value x do you record?
0.87899 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A prescription reads 1 tsp of an oral suspension every 6 hours for 14 days. The suspension comes in 50 mL bottles. Using 1 tsp = 5 mL, how many whole bottles N must be supplied so the course is complete?
1 tspevery 6 hours14 days50 mL1 tsp = 5 mL
N =
27.Dosage calculationsMedium
A child weighing 24 kg is prescribed 5 mg/kg of a drug. The stock solution contains 50 mg/mL. Draw up the dose: what volume V do you give?
24 kg5 mg/kg50 mg/mL
V = mL
28.Dosage calculationsHard
A patient weighs 61.6 lb. The prescription is 10 mg/kg as a single dose, and the stock contains 250 mg in 5 mL. Using 1 kg = 2.2 lb, what volume V do you give?
61.6 lb10 mg/kg250 mg/5 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 60 mL/h, but no pump is available. It runs by gravity through a giving set of 20 gtt/mL. Find the drip rate R in drops per minute.
60 mL/h20 gtt/mL
R = gtt/min
30.IV infusion ratesHard
An infusion of 400 mg in 500 mL runs at 15 mL/h. How many micrograms per minute D does the patient receive?
400 mg/500 mL15 mL/h
D = mcg/min
31.Pediatric & critical-care dosingMedium
Practice exercise (made-up values, not clinical guidance). A practice protocol calls for a heparin bolus of 80 units/kg for a patient who weighs 58 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg58 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A patient who weighs 60 kg has an order for nitroglycerin at 10 mcg/min. The bag contains 50 mg in 250 mL. Find the pump rate R in mL/h. Round to one decimal place.
50 mg/250 mL10 mcg/min60 kg
R = mL/h
33.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the total intake I in mL.
jelly: 120 mLwater: 250 mLIV infusion: 60 mL/h × 12 hIV antibiotic: 1 × 50 mL
I = mL
34.IV fluids & fluid balanceHard
Practice exercise (made-up values, not clinical guidance). A 1000 mL bag runs by pump at 100 mL/h. At 10:00, 600 mL have already been infused. How many hours t until the bag is empty? Round to one decimal place.
1000 mL600 mL infused100 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 10, with E2 and V4. What motor score M was recorded, and which response does it describe? Give the number.
GCS 10E2V4
M =
36.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). Use the NEWS2 chart (SpO₂ scale 1) for these observations: respiration rate 14/min, SpO₂ 86% on room air, blood pressure 136/82 mmHg, pulse 76/min, alert, temperature 37.6 °C. Which clinical risk group does the patient fall into? Click it.
RR 14SpO₂ 86%airSBP 136HR 76AT 37.6 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice gas shows a metabolic acidosis with HCO₃⁻ 10 mmol/L. Use Winter’s formula to find the expected PaCO₂ (the centre of the range) in mmHg.
HCO₃⁻ 10 mmol/L
PaCO₂ = mmHg
38.Arterial blood gas interpretationHard
A practice gas shows pH 7.32, PaCO₂ 28 mmHg (3.7 kPa) and HCO₃⁻ 14 mmol/L, with Na⁺ 132 and Cl⁻ 89 mmol/L. Use the anion gap and the delta ratio to click the best interpretation.
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, so the atria and the ventricles beat at different rates. The QRS complexes are regular: find the ventricular 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
ventricular rate = bpm
3Solutions
1.Nursing fundamentals
Answer: C · Past the internal sphincter, against the rectal wall
Why this is the answer
The suppository is pushed past the internal anal sphincter and placed against the rectal wall, usually with the patient lying on the left side. Placing it in stool stops absorption.
Answer
C · Past the internal sphincter, against the rectal wall
2.Nursing fundamentals
Answer: C · Take it out of use, label it as faulty and report it
Why this is the answer
Damaged electrical equipment can cause shocks or fires. It is removed from use, clearly labelled and reported for repair, and a safe replacement is found.
Answer
C · Take it out of use, label it as faulty and report it
3.Infection control & patient safety
Answer: C · To reduce skin bacteria and bloodstream infections linked to central lines
Why this is the answer
Daily chlorhexidine bathing lowers the number of organisms on the skin, reducing central line-associated bloodstream infections and the spread of resistant bacteria in ICUs.
Answer
C · To reduce skin bacteria and bloodstream infections linked to central lines
4.Infection control & patient safety
Answer: B · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg
Why this is the answer
qSOFA scores one point each for a respiratory rate of 22/min or more, altered mental status and a systolic BP of 100 mmHg or less. Two or more points mean higher risk, so the first patient needs urgent escalation.
Answer
B · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg
5.Prioritization & delegation
Answer: B · An unresponsive patient with gasping, irregular breaths
Why this is the answer
An unresponsive patient with agonal breathing needs immediate airway and breathing support, which is ESI level 1. Chest pain with normal vital signs is high risk (level 2), and the others are lower levels.
Answer
B · An unresponsive patient with gasping, irregular breaths
6.Prioritization & delegation
Answer: A · Morning vital signs on the four stable patients
Why this is the answer
Routine vital signs on stable patients can be delegated, freeing the RN to assess and treat the unstable patient. Assessment, IV medication and explaining a new diagnosis stay with the RN.
Answer
A · Morning vital signs on the four stable patients
7.Clinical nursing
Answer: B · Constipation
Why this is the answer
Opioids slow gut movement, and constipation persists with long-term use. A regular laxative is usually prescribed together with the opioid.
Answer
B · Constipation
8.Clinical nursing
Answer: B · Review and stop treatments that no longer help, and focus on comfort
Why this is the answer
When dying is recognised, non-beneficial interventions are stopped and anticipatory medicines for symptoms such as pain, agitation and secretions are prescribed. Clear communication with the patient and family is essential.
Answer
B · Review and stop treatments that no longer help, and focus on comfort
9.Lab values & electrolytes
Answer: B · Just before the meal, giving insulin when the food is ready
Why this is the answer
Rapid-acting insulin starts working within about 15 minutes, so glucose is checked before the meal and the insulin is given when the meal is available, usually within 15 minutes of eating. Giving it without food can cause hypoglycemia.
Answer
B · Just before the meal, giving insulin when the food is ready
10.Lab values & electrolytes
Answer: C · Several medicines that raise potassium are being taken together
Why this is the answer
ACE inhibitors and spironolactone both make the kidneys retain potassium, and a supplement adds more. The nurse holds the supplement, informs the prescriber and checks kidney function and the ECG.Checked against:High potassium level · MedlinePlus (NIH) (2025); Spironolactone · MedlinePlus (NIH) (2018)
Answer
C · Several medicines that raise potassium are being taken together
11.Pharmacology
Answer: B · Full blood count and serum sodium
Why this is the answer
Carbamazepine can rarely cause bone marrow suppression and commonly lowers serum sodium. Blood counts, sodium and liver tests are checked, especially early in treatment.
Answer
B · Full blood count and serum sodium
12.Pharmacology
Answer: D · Reliable contraception and pregnancy tests, as it is highly teratogenic
Why this is the answer
Isotretinoin causes severe birth defects. Pregnancy prevention programmes require effective contraception and regular pregnancy tests before, during and after treatment.
Answer
D · Reliable contraception and pregnancy tests, as it is highly teratogenic
13.Med-surg: cardiovascular & respiratory
Answer: C · 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
C · Discuss switching medicine with the prescriber before trying to conceive
14.Med-surg: cardiovascular & respiratory
Answer: D · The right coronary artery usually supplies the AV node
Why this is the answer
In most people the right coronary artery supplies the inferior wall and the AV node, so inferior MI can cause AV block. It is often temporary and may respond to atropine, but symptomatic or persistent block may need temporary pacing.
Answer
D · The right coronary artery usually supplies the AV node
15.Med-surg: neuro, endocrine & renal
Answer: D · Heat can briefly worsen MS symptoms, which settle when they cool down
Why this is the answer
Heat sensitivity (Uhthoff's phenomenon) is common in MS. A rise in body temperature slows conduction in demyelinated nerves and temporarily worsens symptoms. It is not a relapse, and the symptoms settle with cooling.
Answer
D · Heat can briefly worsen MS symptoms, which settle when they cool down
16.Med-surg: neuro, endocrine & renal
Answer: A · Fluid is being removed too quickly
Why this is the answer
Muscle cramps and hypotension during dialysis are often due to rapid or excessive fluid removal. Staff may reduce the ultrafiltration rate and give saline per protocol. The dry weight may need to be reviewed.
Answer
A · Fluid is being removed too quickly
17.Med-surg: GI, perioperative & oncology
Answer: C · To detect heparin-induced thrombocytopenia
Why this is the answer
Heparin-induced thrombocytopenia is an immune reaction, usually 5–10 days after starting heparin, that lowers platelets and paradoxically causes thrombosis. Monitoring depends on risk and local policy.
Answer
C · To detect heparin-induced thrombocytopenia
18.Med-surg: GI, perioperative & oncology
Answer: D · Hepatorenal syndrome
Why this is the answer
In hepatorenal syndrome, severe vasodilation in advanced liver disease reduces kidney perfusion, causing kidney failure without another cause. It carries a poor prognosis and is managed by specialists, often with albumin and vasoconstrictors.
Answer
D · Hepatorenal syndrome
19.Maternity & obstetric nursing
Answer: A · Maternal HIV infection
Why this is the answer
A scalp electrode punctures fetal skin and could transmit blood-borne infections such as HIV, hepatitis B or C and herpes. It needs ruptured membranes, some dilation and an identifiable presenting part.
Answer
A · Maternal HIV infection
20.Maternity & obstetric nursing
Answer: A · Give fast-acting glucose by mouth and recheck
Why this is the answer
An alert patient with hypoglycaemia is given fast-acting oral carbohydrate, then glucose is rechecked after about 15 minutes and followed by a snack or meal. Treating the mother also protects the fetus.
Answer
A · Give fast-acting glucose by mouth and recheck
21.Pediatric nursing
Answer: A · Give it with a syringe or straw towards the back of the mouth; dark stools are expected
Why this is the answer
Liquid iron can stain teeth, so it is given by syringe or straw and the teeth are brushed afterwards. Milk and antacids reduce absorption, while vitamin C can help. Dark stools are a harmless, expected effect.
Answer
A · Give it with a syringe or straw towards the back of the mouth; dark stools are expected
22.Pediatric nursing
Answer: B · Slower breathing, easier speech and less use of the neck and chest muscles
Why this is the answer
Improvement shows as a lower respiratory rate, easier speech, less accessory muscle use and better oxygen saturation. A quiet chest with drowsiness signals exhaustion and danger, and tripod positioning shows ongoing distress.
Answer
B · Slower breathing, easier speech and less use of the neck and chest muscles
23.Mental health nursing
Answer: B · "I don't hear the voices, but I can see they are upsetting you. What are they saying to you?"
Why this is the answer
The nurse does not argue or agree, but states their own reality, shows empathy and asks about the content, especially command hallucinations that could put the patient or others at risk.
Answer
B · "I don't hear the voices, but I can see they are upsetting you. What are they saying to you?"
24.Mental health nursing
Answer: D · Look for medical causes, such as delirium, medicines, infection or a neurocognitive disorder
Why this is the answer
New psychosis in an older adult needs a full medical work-up. Delirium, medicine effects, infections, metabolic problems, dementia and brain lesions are common causes.
Answer
D · Look for medical causes, such as delirium, medicines, infection or a neurocognitive disorder
25.Nursing math & unit conversions
Answer: x = 0.88 mL
Rounding: look at the digit just after the place you round to: 5 or more rounds up, 4 or less leaves the digit as it is. Round only the final answer, never the steps. Typical exam rules: volumes of 1 mL or more to the nearest tenth, volumes below 1 mL to the nearest hundredth, drip rates to whole drops and weights to one decimal place; always follow the rule the question states.
Digit in the hundredths place
0.87899 → 7
Only the next digit decides
0.87899 → 8
8 is 5 or more, so round 7 up.
The digits after it (99) are ignored: round once, never step by step.
Round
x = 0.88 mL
Answer
x = 0.88 mL
26.Nursing math & unit conversions
Answer: N = 6
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
5 mL × 4 × 14 = 280 mL
Bottles
280/50 = 5.6 → N = 6
Answer
N = 6
27.Dosage calculations
Answer: V = 2.4 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 5·24 = 120 mg
Volume
V = 120/50 = 2.4 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 2.4 mL
28.Dosage calculations
Answer: V = 5.6 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.
Weight in kg
61.6/2.2 = 28 kg
Dose
10·28 = 280 mg
Volume
V = (280/250)·5 = 5.6 mL
Answer
V = 5.6 mL
29.IV infusion rates
Answer: R = 20 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.
Millilitres per minute
60/60 = 1 mL/min
Drip rate
R = 1·20 = 20 gtt/min
Answer
R = 20 gtt/min
30.IV infusion rates
Answer: D = 200 mcg/min
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
400000 mcg/500 mL = 800 mcg/mL
Dose per hour
15·800 = 12000 mcg/h
Dose per minute
D = 12000/60 = 200 mcg/min
Answer
D = 200 mcg/min
31.Pediatric & critical-care dosing
Answer: V = 4.6 mL
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 needed
80·58 = 4 640 units
Volume
V = 4640/1000 = 4.64 ≈ 4.6 mL
Answer
V = 4.6 mL
32.Pediatric & critical-care dosing
Answer: R = 3 mL/h
Titrated drips: first find the concentration in mcg/mL (mg × 1000/mL). For a weight-based order, mcg/min = mcg/kg/min × weight. Then mL/h = mcg/min × 60/concentration. Working backwards, mcg/kg/min = mL/h × concentration/(60 × weight). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Concentration
50 000/250 = 200 mcg/mL
Dose per hour
The order is per minute for the whole patient, so the weight is not needed.
10·60 = 600 mcg/h
Pump rate
R = 600/200 = 3 mL/h
Answer
R = 3 mL/h
33.IV fluids & fluid balance
Answer: I = 1140 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: 120 + 250 = 370 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 1·50 = 50 mL
I = 1140 mL
Answer
I = 1140 mL
34.IV fluids & fluid balance
Answer: t = 4 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Volume left
1000 − 600 = 400 mL
Time
t = 400/100 = 4 h
Answer
t = 4 h
That is about 4 h 00 min, so the bag runs out at about 14:00.
35.Clinical assessment scores
Answer: M = 4
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Motor score
M = 10 − 2 − 4 = 4
M4: withdraws the limb from pressure (normal flexion)
Answer
M = 4
36.Clinical assessment scores
Answer: low–medium
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 14/min → 0
SpO₂ 86% → 3
on air → 0
SBP 136 mmHg → 0
HR 76/min → 0
alert (A) → 0
T 37.6 °C → 0
Total and red scores
NEWS2 = 0 + 3 + 0 + 0 + 0 + 0 + 0 = 3
At least one parameter scores 3.
Risk group
low–medium
Answer
low–medium
A single score of 3 needs an urgent review even when the total is low.
37.Arterial blood gas interpretation
Answer: PaCO₂ = 23 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 = 1.5·10 + 8 = 23 mmHg
range: 21–25 mmHg
Answer
PaCO₂ = 23 mmHg
38.Arterial blood gas interpretation
Answer: pure high-gap acidosis
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.
Anion gap
AG = 132 − (89 + 14) = 29
Delta ratio
(29 − 12)/(24 − 14) = 1.7
pure high-gap acidosis
Answer
pure high-gap acidosis
39.ECG rhythm strip interpretation
Answer: QT = 0.38 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
9.5 small boxes from the start of the QRS to the end of the T wave
Convert
QT = 9.5 × 0.04 s = 0.38 s
Answer
QT = 0.38 s
A rough rule: at normal rates the QT should be less than half the R–R interval (here R–R = 0.64 s).
40.ECG rhythm strip interpretation
Answer: ventricular rate = 38 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 = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 ≈ 75 per minute
Ventricular rate
R–R = 40 small boxes = 1.60 s → 1500 ÷ 40 = 37.5 ≈ 38 per minute
Answer
ventricular rate = 38 bpm
Answer
ventricular rate = 38 bpm
2:1 AV block: every second P wave is not conducted, so the atrial rate is twice the ventricular rate.
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