Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
Read the pH: below 7.35 is acidosis, above 7.45 alkalosis.
Find the value that explains it: PaCO₂ moving opposite to the pH is respiratory, HCO₃⁻ moving with the pH is metabolic.
Look at the other value: normal means uncompensated, abnormal in the compensating direction means partial compensation, and a normal pH with both abnormal means full compensation.
In a metabolic acidosis, compare PaCO₂ with Winter’s formula, 1.5·HCO₃⁻ + 8 ± 2, and calculate the anion gap Na⁺ − (Cl⁻ + HCO₃⁻).
Check a high anion gap with the delta ratio and, when albumin is low, with the corrected gap.
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.Nursing fundamentalsMedium
A student nurse is asked to carry out a procedure they have not been trained to do. What should they do?
AWatch a video and then do it alone
BAsk the patient to talk them through it
CExplain that they have not been trained and ask for supervision
DDo it anyway, carefully, to avoid upsetting the team or delaying care
2.Nursing fundamentalsHard
A patient on regular paracetamol (acetaminophen) also takes an over-the-counter cold and flu remedy. Why is this a concern?
AParacetamol makes cold remedies cause drowsiness
BThere is no concern, as cold remedies contain no drugs
CCold remedies stop paracetamol from working, so the pain will not be controlled
DMany cold remedies also contain paracetamol, risking liver damage
3.Infection control & patient safetyMedium
Why are patients on long-term corticosteroids at higher risk from infections?
ASteroids suppress the immune response and can hide signs of infection
BSteroids make the patient’s blood more acidic, which helps bacteria grow
CSteroids only affect the risk of fungal skin rashes
DSteroids kill the patient’s normal skin bacteria
4.Infection control & patient safetyHard
During flu season, a nurse wakes up with fever, cough and muscle aches. What is the best action?
AGo to work but wear a surgical mask for the whole shift
BStay home and inform the employer according to the illness policy
CTake an antipyretic so the fever does not show at work
DGo to work but avoid caring for patients who have weak immune systems
5.Prioritization & delegationMedium
A patient has a sudden nosebleed, is alert and is breathing normally. What does the nurse do first?
ASit the patient up, lean them forward and pinch the soft part of the nose
BTilt the head back and apply ice to the back of the neck
CAsk the patient to blow the nose hard to clear the clots
DLie the patient flat on their back with a pillow under the knees
6.Prioritization & delegationHard
Six hours after surgery, a patient has not passed urine, feels the urge to go and has a firm swelling above the pubic bone. What is the most likely problem?
ADehydration from fasting before surgery
BA normal effect of the anesthetic
CUrinary retention
DAcute kidney injury with no urine made
7.Clinical nursingMedium
Which is a first-line nursing measure to help prevent constipation in hospital?
AEncouraging fluids, fibre and mobility
BRestricting fluids to reduce urine output
CKeeping the patient in bed
DGiving an enema to every patient on admission
8.Clinical nursingHard
A patient with stress incontinence is taught self-care. Which statement shows a need for further teaching?
A"I'll try to lose some weight if I can."
B"I'll cut down on caffeine."
C"I'll drink as little as possible so I don't leak."
D"I'll do my pelvic floor exercises every day."
9.Lab values & electrolytesMedium
An older adult takes lisinopril and furosemide and recently started daily ibuprofen for knee pain. The creatinine has risen from 1.0 to 1.8 mg/dL (88 to 159 µmol/L). What is the most likely cause?
AA laboratory error, since ibuprofen has no effect on the kidney
BNormal aging of the kidneys over a period of a few weeks
CThe NSAID reduces kidney blood flow on top of the other two drugs
DMore activity has increased the patient's muscle mass quickly
10.Lab values & electrolytesHard
After lying on the floor for many hours, a patient has a CK of 40,000 U/L, a potassium of 6.1 mEq/L and dark urine. Which prescribed treatment is the priority?
AFluid restriction to protect the heart from overload
BHigh-dose NSAIDs for the muscle pain
CAn oral potassium supplement with each meal
DLarge-volume IV fluids with cardiac monitoring
11.PharmacologyMedium
Which advice helps reduce the most common side effect of varenicline?
ATake double doses in the first week
BTake it with alcohol to reduce nausea
CTake it after food with a full glass of water
DTake it on an empty stomach at bedtime with a little milk
12.PharmacologyHard
Before starting rituximab, patients are tested for hepatitis B. Why?
ARituximab is a vaccine against hepatitis B
BRituximab is made from the hepatitis B virus
CRituximab can reactivate hepatitis B and cause liver failure
DHepatitis B infection makes rituximab completely ineffective
13.Med-surg: cardiovascular & respiratoryMedium
Before compression therapy is applied for a venous leg ulcer, which assessment is essential?
AAn ankle–brachial pressure index (ABPI)
BA full blood count and CRP
CA wound swab for culture and sensitivity
DA chest X-ray and ECG
14.Med-surg: cardiovascular & respiratoryHard
A nurse reviews inhaler use with a patient who has asthma and uses a separate steroid preventer inhaler and a salbutamol reliever. Which statement shows a need for further teaching?
A"I carry my blue reliever inhaler with me."
B"I rinse my mouth after the steroid inhaler."
C"I use my steroid inhaler every day, even when I feel well."
D"I use my steroid inhaler when I start to wheeze."
15.Med-surg: neuro, endocrine & renalMedium
Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?
ATo reduce stomach acid so the food is digested better
BTo lower the blood glucose rise after eating a meal
CTo improve the strength of chewing and swallowing at mealtimes
DTo stop the drug from irritating an empty stomach later on
16.Med-surg: neuro, endocrine & renalHard
A patient on long-term high-dose prednisolone is three days after bowel surgery. They report only mild abdominal pain, but the heart rate has risen to 115/min and the temperature is 37.4 °C. Why should the nurse be especially concerned?
ASteroids cause tachycardia in all patients, so no action is needed
BThe mild pain shows that the bowel is healing as expected
CSteroids can mask fever, pain and peritonism, hiding complications
DSteroids protect against infection, so sepsis is very unlikely
17.Med-surg: GI, perioperative & oncologyMedium
Which statement about pain in older adults is correct?
AOpioids must never be used in people over 70
BPain is a normal part of ageing and does not need any treatment at all
COlder adults feel less pain because nerves wear out
DThey may under-report pain, so active assessment is needed
18.Med-surg: GI, perioperative & oncologyHard
A patient on immunotherapy for melanoma has six watery stools a day and abdominal cramps. What should the nurse do?
AGive loperamide and review next week
BEscalate urgently, as immune-related colitis is likely
CReassure that diarrhoea is normal and harmless
DAdvise eating more fibre and fruit to firm up the stools
19.Maternity & obstetric nursingMedium
When should an Rh-negative woman with no anti-D antibodies routinely receive antenatal anti-D immunoglobulin?
AOnly if the baby is known to be Rh-negative
BAfter she has formed anti-D antibodies
COnly at the first antenatal visit
DAt about 28 weeks of pregnancy
20.Maternity & obstetric nursingHard
An Rh-negative mother's baby is found to be Rh-negative. What is the correct action regarding postnatal anti-D?
AGive a double dose of anti-D
BGive anti-D to the baby instead
CPostnatal anti-D is not needed
DGive anti-D only if the mother had a miscarriage before
21.Pediatric nursingMedium
How should the nurse position the ear when giving ear drops to a 2-year-old?
ALeave the pinna alone and tilt the head
BPull the earlobe gently forward and up
CPull the pinna gently up and back
DPull the pinna gently down and back
22.Pediatric nursingHard
A 10-year-old has vomiting, abdominal pain, deep rapid breathing and a fruity smell on the breath. His blood glucose is very high. What is the most likely diagnosis?
AAcute asthma attack with hyperventilation
BDiabetic ketoacidosis
CGastroenteritis
DAppendicitis
23.Mental health nursingMedium
Which factor is one of the strongest predictors of future suicide?
ABeing married
BHaving a strong religious faith
CHaving a stable job
DA previous suicide attempt
24.Mental health nursingHard
For the last 3 years a man has had frequent periods of mildly raised mood and periods of low mood. None has been severe enough to count as hypomania or a major depressive episode. Which diagnosis fits best?
ABipolar I disorder
BBipolar II disorder
CMajor depressive disorder
DCyclothymic disorder
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A dose calculation for a small injection gives 0.10836 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?
0.10836 mL
x = mL
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). A serum creatinine result is 4.3 mg/dL. Using 1 mg/dL = 88.4 µmol/L for creatinine, find c in µmol/L to the nearest whole number.
4.3 mg/dL1 mg/dL = 88.4 µmol/L
c = µmol/L
27.Dosage calculationsMedium
A patient weighs 90 kg. The prescribed dose is 2 mg/kg per day, given in 2 equal doses. How many milligrams D are given per dose?
90 kg2 mg/kg/day2× per day
D = mg
28.Dosage calculationsHard
A child weighing 10 kg is prescribed 20 mg/kg per dose of an oral suspension that contains 250 mg in 5 mL. What volume V do you give?
10 kg20 mg/kg250 mg/5 mL
V = mL
29.IV infusion ratesMedium
A drip runs at 35 gtt/min through a set of 15 gtt/mL. How many millilitres V does the patient receive in 3 hours?
35 gtt/min15 gtt/mL3 h
V = mL
30.IV infusion ratesHard
A drip runs at 28 gtt/min through a set of 15 gtt/mL. There are 750 mL left in the bag. How many hours t until it is empty? Round to one decimal place.
28 gtt/min15 gtt/mL750 mL
t = h
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 108 kg. The vial contains 1 000 units/mL. What volume V do you draw up? Round to one decimal place.
80 units/kg108 kg1 000 units/mL
V = mL
32.Pediatric & critical-care dosingHard
Practice exercise (made-up values, not clinical guidance). A bag contains dopamine 400 mg in 250 mL. The order is 10 mcg/kg/min for a patient who weighs 62 kg. At what rate R do you set the pump, in mL/h? Round to one decimal place.
400 mg/250 mL10 mcg/kg/min62 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.
juice: 150 mLjelly: 120 mLsoup: 250 mLIV infusion: 100 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 infusion starts at 12:30 at 75 mL/h. After 2 hours the rate is changed to 100 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL75 mL/h · 2 h100 mL/h
t = h
35.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 13, with E3 and V4. What motor score M was recorded, and which response does it describe? Give the number.
GCS 13E3V4
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 20/min, SpO₂ 90% on supplemental oxygen, blood pressure 136/82 mmHg, pulse 88/min, alert, temperature 37.9 °C. Which clinical risk group does the patient fall into? Click it.
RR 20SpO₂ 90%O₂SBP 136HR 88AT 37.9 °C
1low
2low–medium
3medium
4high
37.Arterial blood gas interpretationMedium
A practice arterial blood gas shows pH 7.36, PaCO₂ 29 mmHg (3.9 kPa) and HCO₃⁻ 16 mmol/L. The primary disorder is metabolic acidosis. How far is it compensated? Click your answer.
pH 7.36PaCO₂ 29 mmHg (3.9 kPa)HCO₃⁻ 16 mmol/L
1uncompensated
2partially compensated
3fully compensated
38.Arterial blood gas interpretationHard
At sea level, a practice gas taken on 21% oxygen shows PaO₂ 92 mmHg (12.3 kPa) and PaCO₂ 32 mmHg (4.3 kPa). Use PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 to find the A–a gradient.
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
1sinus bradycardia
2normal sinus rhythm
3sinus arrhythmia
4sinus rhythm with PVCs
40.ECG rhythm strip interpretationHard
Identify the rhythm on this lead II strip. 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
1idioventricular rhythm
2torsades de pointes
3atrial flutter, 2:1 conduction
4ventricular fibrillation
3Solutions
1.Nursing fundamentals
Answer: C · Explain that they have not been trained and ask for supervision
Why this is the answer
Nurses and students must only practise within their competence. Saying so, and asking to observe or be supervised, protects the patient and the student.
Answer
C · Explain that they have not been trained and ask for supervision
2.Nursing fundamentals
Answer: D · Many cold remedies also contain paracetamol, risking liver damage
Why this is the answer
Paracetamol is in many combination products. Taking several at once can push the total over the safe daily maximum and cause liver damage, so patients are taught to check labels.
Answer
D · Many cold remedies also contain paracetamol, risking liver damage
3.Infection control & patient safety
Answer: A · Steroids suppress the immune response and can hide signs of infection
Why this is the answer
Corticosteroids reduce white cell activity and inflammation, so infections develop more easily and may cause less fever or redness. Nurses watch closely for subtle signs.
Answer
A · Steroids suppress the immune response and can hide signs of infection
4.Infection control & patient safety
Answer: B · Stay home and inform the employer according to the illness policy
Why this is the answer
Health care workers with signs of influenza should not work, because they can infect patients and colleagues. They follow the employer’s policy on when they may return.
Answer
B · Stay home and inform the employer according to the illness policy
5.Prioritization & delegation
Answer: A · Sit the patient up, lean them forward and pinch the soft part of the nose
Why this is the answer
Leaning forward keeps blood out of the airway and stomach, and firm pressure on the soft part of the nose usually stops the bleeding. Tilting the head back or lying flat lets blood run into the throat.
Answer
A · Sit the patient up, lean them forward and pinch the soft part of the nose
6.Prioritization & delegation
Answer: C · Urinary retention
Why this is the answer
An urge to void with a palpable bladder points to retention, not reduced urine production. The nurse confirms with a bladder scan if available and follows the prescribed plan, such as catheterization.
Answer
C · Urinary retention
7.Clinical nursing
Answer: A · Encouraging fluids, fibre and mobility
Why this is the answer
Adequate fluids, a fibre-rich diet, mobility and privacy for toileting help prevent constipation. Laxatives are added if needed, especially with opioids.
Answer
A · Encouraging fluids, fibre and mobility
8.Clinical nursing
Answer: C · "I'll drink as little as possible so I don't leak."
Why this is the answer
Restricting fluids concentrates urine, irritates the bladder and risks dehydration and infection. Pelvic floor exercises, weight loss and reducing caffeine are recommended measures.
Answer
C · "I'll drink as little as possible so I don't leak."
9.Lab values & electrolytes
Answer: C · The NSAID reduces kidney blood flow on top of the other two drugs
Why this is the answer
NSAIDs reduce prostaglandin-driven blood flow to the kidney. Combined with an ACE inhibitor and a diuretic, this can cause acute kidney injury, especially in older adults. The nurse reports the result and the NSAID is usually stopped.Checked against:Creatinine blood test · MedlinePlus (NIH) (2025)
Answer
C · The NSAID reduces kidney blood flow on top of the other two drugs
10.Lab values & electrolytes
Answer: D · Large-volume IV fluids with cardiac monitoring
Why this is the answer
Rhabdomyolysis releases myoglobin, which can cause acute kidney injury, and potassium, which can cause arrhythmias. Early aggressive IV fluids, a target urine output and cardiac monitoring are priorities. NSAIDs and potassium would worsen kidney injury and hyperkalemia.Checked against:Rhabdomyolysis · MedlinePlus (NIH) (2025)
Answer
D · Large-volume IV fluids with cardiac monitoring
11.Pharmacology
Answer: C · Take it after food with a full glass of water
Why this is the answer
Nausea is the most common adverse effect of varenicline and is reduced by taking it after food with water. Patients should also report changes in mood or behaviour.
Answer
C · Take it after food with a full glass of water
12.Pharmacology
Answer: C · Rituximab can reactivate hepatitis B and cause liver failure
Why this is the answer
Rituximab destroys CD20-positive B cells, weakening control of latent hepatitis B. Reactivation can cause fulminant hepatitis, so carriers receive monitoring or antiviral prophylaxis.
Answer
C · Rituximab can reactivate hepatitis B and cause liver failure
13.Med-surg: cardiovascular & respiratory
Answer: A · An ankle–brachial pressure index (ABPI)
Why this is the answer
Compression helps venous return but can cause tissue necrosis if the arterial supply is inadequate. The ABPI compares ankle and arm systolic pressures; a value below about 0.8 (or above about 1.3, suggesting calcified vessels) needs specialist review before compression.
Answer
A · An ankle–brachial pressure index (ABPI)
14.Med-surg: cardiovascular & respiratory
Answer: D · "I use my steroid inhaler when I start to wheeze."
Why this is the answer
Inhaled corticosteroids are preventers that reduce airway inflammation over days to weeks and must be taken regularly. They do not relieve an acute wheeze. Unless the patient has a combined reliever and maintenance regimen, a short-acting bronchodilator is used for symptoms.
Answer
D · "I use my steroid inhaler when I start to wheeze."
15.Med-surg: neuro, endocrine & renal
Answer: C · To improve the strength of chewing and swallowing at mealtimes
Why this is the answer
Pyridostigmine inhibits acetylcholinesterase, so more acetylcholine is available at the neuromuscular junction. Timing it before meals gives the best muscle strength for chewing and swallowing, which lowers the risk of aspiration.
Answer
C · To improve the strength of chewing and swallowing at mealtimes
16.Med-surg: neuro, endocrine & renal
Answer: C · Steroids can mask fever, pain and peritonism, hiding complications
Why this is the answer
Long-term steroids blunt fever, pain and abdominal rigidity, so an anastomotic leak, abscess or perforation may present only with subtle signs such as tachycardia. The nurse should assess thoroughly and escalate early. These patients also need steroid cover around surgery to prevent adrenal crisis.
Answer
C · Steroids can mask fever, pain and peritonism, hiding complications
17.Med-surg: GI, perioperative & oncology
Answer: D · They may under-report pain, so active assessment is needed
Why this is the answer
Older adults may minimise pain or have cognitive or sensory problems that hinder reporting. Regular assessment with suitable tools and careful analgesia, starting low and adjusting slowly, are recommended.
Answer
D · They may under-report pain, so active assessment is needed
18.Med-surg: GI, perioperative & oncology
Answer: B · Escalate urgently, as immune-related colitis is likely
Why this is the answer
Severe diarrhoea on checkpoint inhibitors suggests immune-mediated colitis, which can perforate. It needs urgent assessment, infection testing and often high-dose steroids, not only antidiarrhoeals.
Answer
B · Escalate urgently, as immune-related colitis is likely
19.Maternity & obstetric nursing
Answer: D · At about 28 weeks of pregnancy
Why this is the answer
Routine antenatal anti-D around 28 weeks, in a single or split dose depending on the programme, protects against sensitisation from silent fetomaternal bleeds. It is given again after birth if the baby is Rh-positive.
Answer
D · At about 28 weeks of pregnancy
20.Maternity & obstetric nursing
Answer: C · Postnatal anti-D is not needed
Why this is the answer
Postnatal anti-D prevents sensitisation to Rh-positive fetal cells. An Rh-negative baby carries no D antigen, so the mother cannot be sensitised by this birth.
Answer
C · Postnatal anti-D is not needed
21.Pediatric nursing
Answer: D · Pull the pinna gently down and back
Why this is the answer
In children under about 3 years the ear canal is short and angled upward, so the pinna is pulled down and back. In older children and adults it is pulled up and back.
Answer
D · Pull the pinna gently down and back
22.Pediatric nursing
Answer: B · Diabetic ketoacidosis
Why this is the answer
Without insulin the body burns fat, producing ketones that cause metabolic acidosis. Deep, rapid (Kussmaul) breathing, a fruity breath smell, vomiting and abdominal pain with high glucose point to DKA, an emergency.
Answer
B · Diabetic ketoacidosis
23.Mental health nursing
Answer: D · A previous suicide attempt
Why this is the answer
A previous attempt greatly raises the risk. Other risk factors include mental disorder, substance use, hopelessness, access to lethal means, recent loss and social isolation. Social support and reasons for living are protective.
Answer
D · A previous suicide attempt
24.Mental health nursing
Answer: D · Cyclothymic disorder
Why this is the answer
Cyclothymic disorder involves at least 2 years (1 year in young people) of many hypomanic and depressive symptoms that do not meet full criteria for hypomanic or major depressive episodes.
Answer
D · Cyclothymic disorder
25.Nursing math & unit conversions
Answer: x = 0.11 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
0.10836 → 0
Only the next digit decides
0.10836 → 8
8 is 5 or more, so round 0 up.
The digits after it (36) are ignored: round once, never step by step.
Round
x = 0.11 mL
Answer
x = 0.11 mL
26.Nursing math & unit conversions
Answer: c = 380 µmol/L
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.
Convert
c = 4.3·88.4 = 380.1 ≈ 380 µmol/L
Answer
c = 380 µmol/L
27.Dosage calculations
Answer: D = 90 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
2·90 = 180 mg
Per dose
D = 180/2 = 90 mg
Answer
D = 90 mg
28.Dosage calculations
Answer: V = 4 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
20·10 = 200 mg
Volume
V = (200/250)·5 = 4 mL
Answer
V = 4 mL
29.IV infusion rates
Answer: V = 420 mL
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
35·60/15 = 140 mL/h
Volume
V = 140·3 = 420 mL
Answer
V = 420 mL
30.IV infusion rates
Answer: t = 6.7 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
28·60/15 = 112 mL/h
Time left
t = 750/112 = 6.696 ≈ 6.7 h
Answer
t = 6.7 h
31.Pediatric & critical-care dosing
Answer: V = 8.6 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
80·108 = 8 640 units
Volume
V = 8640/1000 = 8.64 ≈ 8.6 mL
Answer
V = 8.6 mL
32.Pediatric & critical-care dosing
Answer: R = 23.3 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
400 mg = 400 000 mcg
400 000/250 = 1600 mcg/mL
Dose per minute and per hour
10·62 = 620 mcg/min
620·60 = 37200 mcg/h
Pump rate
R = 37200/1600 = 23.25 ≈ 23.3 mL/h
Answer
R = 23.3 mL/h
33.IV fluids & fluid balance
Answer: I = 1770 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: 150 + 120 + 250 = 520 mL
IV infusion: 100·12 = 1200 mL
IV antibiotic: 1·50 = 50 mL
I = 1770 mL
Answer
I = 1770 mL
34.IV fluids & fluid balance
Answer: t = 10.5 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.
First part
75·2 = 150 mL
1000 − 150 = 850 mL left
Second part
850/100 = 8.5 h
Total time
t = 2 + 8.5 = 10.5 h
Answer
t = 10.5 h
That is about 10 h 30 min, so the bag runs out at about 23:00.
35.Clinical assessment scores
Answer: M = 6
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 = 13 − 3 − 4 = 6
M6: obeys commands
Answer
M = 6
36.Clinical assessment scores
Answer: 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 20/min → 0
SpO₂ 90% → 3
on oxygen → 2
SBP 136 mmHg → 0
HR 88/min → 0
alert (A) → 0
T 37.9 °C → 0
Total and red scores
NEWS2 = 0 + 3 + 2 + 0 + 0 + 0 + 0 = 5
At least one parameter scores 3.
Risk group
medium
Answer
medium
A total of 5 or more calls for an urgent clinical response.
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 7.36: within 7.35–7.45
PaCO₂ 29 mmHg: low (35–45)
HCO₃⁻ 16 mmol/L: low (22–26)
Compensation
Clinically, also check the expected compensation: Winter’s formula expects PaCO₂ 30–34 mmHg, so the measured 29 mmHg points to an additional respiratory alkalosis (a mixed disorder). The answer above is the ROME exam classification.
fully compensated
Answer
fully compensated
38.Arterial blood gas interpretation
Answer: A–a gradient = 17.73 mmHg
Derived values: calculated serum osmolality is 2·Na⁺ + glucose + urea with all values in mmol/L (2·Na⁺ + glucose/18 + BUN/2.8 with glucose and BUN in mg/dL); normal is about 275–295 mOsm/kg. The P/F ratio is PaO₂ divided by FiO₂ as a fraction. The alveolar oxygen pressure is PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg at sea level, and the A–a gradient is PAO₂ − PaO₂.
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: 7 QRS complexes in 6 s, × 10 = 70 per minute.
2. Rhythm: irregular, R–R from 0.76 to 1.06 s, lengthening and shortening gradually.
3. P waves: upright, one before every QRS, all alike.
4. PR interval: 0.16 s, constant, within 0.12–0.20 s.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
sinus arrhythmia
Answer
sinus arrhythmia
40.ECG rhythm strip interpretation
Answer: torsades de pointes
More ventricular rhythms: torsades de pointes is a polymorphic ventricular tachycardia, usually 150–250/min, in which the wide complexes change in height and twist around the baseline, pointing up for a few beats and then down. Textbooks link it to a prolonged QT interval, and magnesium sulfate is the drug resuscitation guidelines name for it. An idioventricular rhythm is a ventricular escape rhythm: regular, wide QRS (0.12 s or more), no P waves, at 20–40/min (an accelerated idioventricular rhythm runs at 40–100/min). Monomorphic VT has identical wide complexes at more than 100/min. VF is chaotic, without any repeating complex.
Five steps
1. Rate: very fast, the complexes are about 6 small boxes apart (about 250 per minute).
2. Rhythm: fast and roughly regular, but the height and direction of the complexes change in a repeating spindle pattern.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: wide and polymorphic; the complexes twist around the baseline, pointing up for a few beats and then down.
Interpretation
torsades de pointes
Answer
torsades de pointes
Torsades de pointes is a polymorphic VT linked to a prolonged QT interval. This is identification practice only.
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