1Formulas and methods
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.
Infection control & patient safety
Method
- Start with standard precautions for every patient: hand hygiene, PPE for the expected exposure, safe sharps.
- Add precautions by route: contact (gown, gloves), droplet (surgical mask), airborne (N95, negative-pressure room).
- 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.
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.
2Practice problems
1.Prioritization & delegationMedium
A nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?
- A“I will make my breath out about twice as long as my breath in.”
- B“I will breathe out slowly through pursed lips.”
- C“I will breathe in through my mouth and out quickly through my nose.”
- D“I will breathe in slowly through my nose.”
2.Prioritization & delegationHard
A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?
- ASkin condition over the heels
- BThe patient’s mood and coping
- CMuscle strength in the feet and ankles at the start of each morning
- DBreathing strength, such as vital capacity and the ability to cough
3.Infection control & patient safetyMedium
Why are independent double checks used for some medicines, such as insulin and heparin infusions?
- ATo make the preparation process faster
- BTo share responsibility between two nurses if an error happens
- CBecause these drugs are very expensive to waste
- DA second person checking separately catches missed errors
4.Infection control & patient safetyHard
A nurse has weeping dermatitis on both hands. What is the most appropriate action?
- AUse extra alcohol hand rub on the lesions
- BContinue care as usual and wear one pair of gloves
- CCover the lesions with a waterproof bandage and keep working with patients as usual
- DAvoid direct patient care and handling of equipment until it heals, and see occupational health
5.Lab values & electrolytesMedium
When is a peak level for an IV aminoglycoside such as gentamicin usually drawn?
- AAt any time convenient for the patient
- BAbout 30 minutes after the infusion ends
- CJust before the next dose is started
- DExactly 24 hours after the first dose
6.Lab values & electrolytesHard
A patient with severe vomiting has a potassium of 3.0 mEq/L, a chloride of 88 mEq/L and a high bicarbonate. What pattern does this show?
- ANormal results that need no follow-up
- BHigh potassium with metabolic acidosis caused by dehydration
- CDiabetic ketoacidosis with a high anion gap
- DLoss of stomach acid: low potassium and chloride, metabolic alkalosis
7.Clinical nursingMedium
What is the recommended first aid for a thermal burn?
- ACool it under cool running water for about 20 minutes
- BBurst any blisters to release the fluid
- CApply ice directly to the burn until the pain stops completely
- DSpread butter or oil over the burn
8.Clinical nursingHard
Why is a large pleural effusion drained slowly rather than all at once?
- ARapid drainage can cause re-expansion pulmonary oedema
- BFluid drained quickly turns into blood
- CSlow drainage stops the patient needing oxygen
- DQuick drainage causes the effusion to spread to the other lung
9.Med-surg: cardiovascular & respiratoryMedium
A patient with asthma uses their reliever inhaler more than three times a week. What does this suggest?
- AAsthma control is poor and treatment needs review
- BThe reliever no longer works and should be stopped
- CThe preventer inhaler is no longer needed
- DAsthma is well controlled with the current plan
10.Med-surg: cardiovascular & respiratoryHard
A patient with a valid, documented do-not-attempt-CPR decision (DNACPR in the UK, DNR or DNAR in the US) is found in cardiac arrest. What should the nurse do?
- AStart full CPR because the patient's family is not present
- BCall the arrest team and let them decide whether to resuscitate
- CStart CPR but use only chest compressions
- DNot start CPR, call for support, and provide dignity and comfort
11.Med-surg: neuro, endocrine & renalMedium
Why must Parkinson's medicines be given on time in hospital?
- ALate doses can soon cause stiffness, falls and poor swallowing
- BGiving them on time prevents the disease from getting worse
- CLate doses build up in the blood and cause an overdose
- DLate doses cause the patient to develop high blood glucose
12.Med-surg: neuro, endocrine & renalHard
A patient with an acute stroke has a glucose of 15 mmol/L (270 mg/dL). They do not have known diabetes. What is appropriate?
- AStop all IV fluids to lower the glucose
- BGive glucose gel to stabilise the level
- CReport it and monitor glucose, as it can worsen outcome
- DIgnore it, because stress always raises glucose
13.Med-surg: GI, perioperative & oncologyMedium
Why is IV hydration given with cisplatin?
- ATo make the drug less effective
- BTo raise the blood pressure during treatment
- CTo prevent hair loss
- DTo protect the kidneys from damage
14.Med-surg: GI, perioperative & oncologyHard
During burn resuscitation, a 70 kg adult's urine output has been 120 mL/h for 3 hours, and the face and limbs are very oedematous. What should the nurse do?
- ADiscuss reducing the fluid rate with the team
- BStop all IV fluids completely and remove the catheter
- CGive a diuretic without discussing it
- DIncrease the fluid rate to keep the output high
3Solutions
1.Prioritization & delegation
Answer: C · “I will breathe in through my mouth and out quickly through my nose.”
Why this is the answer
Pursed-lip breathing means breathing in through the nose and out slowly through pursed lips, making exhalation longer. This keeps airways open and reduces air trapping.
C · “I will breathe in through my mouth and out quickly through my nose.”
2.Prioritization & delegation
Answer: D · Breathing strength, such as vital capacity and the ability to cough
Why this is the answer
Guillain-Barré syndrome causes ascending weakness that can involve the respiratory muscles. Falling vital capacity or a weak cough can mean the patient needs ventilation, so breathing is monitored closely.
D · Breathing strength, such as vital capacity and the ability to cough
3.Infection control & patient safety
Answer: D · A second person checking separately catches missed errors
Why this is the answer
In an independent double check, a second qualified person checks the order, the drug, the dose, the calculation and the pump settings on their own. This catches errors that could cause serious harm with high-alert medications.
D · A second person checking separately catches missed errors
4.Infection control & patient safety
Answer: D · Avoid direct patient care and handling of equipment until it heals, and see occupational health
Why this is the answer
Weeping skin lesions increase the risk of passing organisms to patients and of the nurse picking up bloodborne pathogens. The nurse should avoid direct patient contact and handling of patient equipment until the condition is assessed and resolved.
D · Avoid direct patient care and handling of equipment until it heals, and see occupational health
5.Lab values & electrolytes
Answer: B · About 30 minutes after the infusion ends
Why this is the answer
Peak aminoglycoside levels are usually drawn about 30 minutes after a 30-minute infusion ends, to confirm the level is high enough to kill bacteria. Troughs, drawn just before the next dose, check for accumulation. Local protocols may differ, especially with once-daily dosing.
B · About 30 minutes after the infusion ends
6.Lab values & electrolytes
Answer: D · Loss of stomach acid: low potassium and chloride, metabolic alkalosis
Why this is the answer
Vomiting removes hydrochloric acid, so chloride falls and bicarbonate rises (metabolic alkalosis). The kidneys then lose potassium. Replacement usually includes 0.9% sodium chloride with potassium as prescribed.Checked against: Alkalosis · StatPearls (NCBI Bookshelf) (2024)
D · Loss of stomach acid: low potassium and chloride, metabolic alkalosis
7.Clinical nursing
Answer: A · Cool it under cool running water for about 20 minutes
Why this is the answer
Cooling with running water for around 20 minutes limits tissue damage and pain. Ice can cause further injury, and the patient should be kept warm while the burn is cooled.
A · Cool it under cool running water for about 20 minutes
8.Clinical nursing
Answer: A · Rapid drainage can cause re-expansion pulmonary oedema
Why this is the answer
Draining a large volume quickly can cause re-expansion pulmonary oedema, with cough, chest tightness and hypoxia. Drainage is controlled, and the patient is watched closely.
A · Rapid drainage can cause re-expansion pulmonary oedema
9.Med-surg: cardiovascular & respiratory
Answer: A · Asthma control is poor and treatment needs review
Why this is the answer
Needing a reliever often, waking at night with symptoms or limiting activity indicates poorly controlled asthma. Inhaler technique, adherence and triggers should be checked and the regular preventer treatment stepped up.
A · Asthma control is poor and treatment needs review
10.Med-surg: cardiovascular & respiratory
Answer: D · Not start CPR, call for support, and provide dignity and comfort
Why this is the answer
A valid do-not-attempt-CPR decision means CPR is not attempted. Other appropriate care continues, the senior team and family are informed and the patient is cared for with dignity. Nurses should check that the decision is valid and applies to the situation.
D · Not start CPR, call for support, and provide dignity and comfort
11.Med-surg: neuro, endocrine & renal
Answer: A · Late doses can soon cause stiffness, falls and poor swallowing
Why this is the answer
People with Parkinson's disease often take doses at exact times. A delay of even 30 minutes or so can cause rigidity, immobility, falls and unsafe swallowing. Many hospitals treat these drugs as time-critical.
A · Late doses can soon cause stiffness, falls and poor swallowing
12.Med-surg: neuro, endocrine & renal
Answer: C · Report it and monitor glucose, as it can worsen outcome
Why this is the answer
Hyperglycaemia is common after stroke and is linked to worse outcomes. It is reported, monitored and treated in line with local protocols, while avoiding hypoglycaemia. The patient may also be tested for undiagnosed diabetes.
C · Report it and monitor glucose, as it can worsen outcome
13.Med-surg: GI, perioperative & oncology
Answer: D · To protect the kidneys from damage
Why this is the answer
Cisplatin is nephrotoxic, so hydration and electrolyte replacement (especially magnesium) are given. It can also cause ototoxicity, neuropathy and severe nausea.
D · To protect the kidneys from damage
14.Med-surg: GI, perioperative & oncology
Answer: A · Discuss reducing the fluid rate with the team
Why this is the answer
An output of about 1.7 mL/kg/h suggests over-resuscitation. Excess fluid ("fluid creep") worsens oedema and can cause pulmonary oedema and compartment syndromes, so the rate is reviewed and reduced under the burn protocol.
A · Discuss reducing the fluid rate with the team
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