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 nursing assistant refuses a delegated task, saying they have not been trained to do it. What is the best response from the nurse?
- AReport the assistant to the manager for refusing a task
- BLeave the task for the next shift, when someone trained is on
- CThank the assistant, make sure the task is done safely and arrange training
- DTell the assistant it is in the job description and must be done
2.Prioritization & delegationHard
At 08:00 a nurse has four tasks. Which order is best?
- AGive routine medications, check the patient with a falling SpO₂, update care plans, give insulin with breakfast
- BCheck the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
- CGive insulin with breakfast, update care plans, check the patient with a falling SpO₂, give routine medications
- DUpdate care plans, give insulin with breakfast, give routine medications, check the patient with a falling SpO₂
3.Infection control & patient safetyMedium
Why are oral liquid medicines given with oral or enteral syringes rather than standard IV syringes?
- AIV syringes cannot measure small volumes of oral liquid accurately
- BOral syringes do not fit IV lines, preventing wrong-route errors
- CThere is no safety reason; it is only tradition
- DOral syringes measure intravenous doses more accurately
4.Infection control & patient safetyHard
A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?
- ACall the family to ask whether the patient has gone home on their own
- BAlert staff and security at once, following the missing-patient procedure
- CWait an hour in case the patient comes back
- DDocument the absence at the end of the shift
5.Lab values & electrolytesMedium
A patient starts lisinopril (an ACE inhibitor). Which laboratory values should the nurse expect to be monitored?
- AALT and bilirubin
- BTSH and free T4
- CPotassium and creatinine
- DCalcium and phosphate
6.Lab values & electrolytesHard
A patient on hemodialysis receives epoetin, but the hemoglobin has not risen in 2 months. Which results should be checked first?
- ATSH and the free T3 level
- BTroponin and creatine kinase
- CAmylase and lipase levels
- DFerritin and transferrin saturation
7.Clinical nursingMedium
What should a nurse do during a generalised tonic-clonic seizure?
- APut a tongue depressor between the teeth so that the tongue is not bitten
- BGive the patient a drink of water
- CHold the limbs firmly to stop the jerking and prevent injury
- DProtect the head, time the seizure and do not put anything in the mouth
8.Clinical nursingHard
A patient on enteral tube feeding after a long period of starvation develops low phosphate, low potassium and arrhythmias. What is most likely?
- ADiabetic ketoacidosis
- BRefeeding syndrome
- CDumping syndrome
- DHyperthyroidism
9.Med-surg: cardiovascular & respiratoryMedium
A patient with diabetes is starting a beta-blocker. What should the nurse teach about hypoglycaemia?
- AHypoglycaemia will always cause a very slow and weak pulse
- BThe beta-blocker will prevent all episodes of hypoglycaemia
- CInsulin should be stopped while taking a beta-blocker
- DSome warning signs, such as a fast heartbeat, may be masked
10.Med-surg: cardiovascular & respiratoryHard
A patient with known left-sided lung cancer starts coughing up large amounts of fresh blood. While help is called, how should the patient be positioned?
- ALying on the right side, with the bleeding lung up
- BProne with the head turned to one side
- CFlat on the back with the head down
- DLying on the left side, with the bleeding lung down
11.Med-surg: neuro, endocrine & renalMedium
Why must potassium be monitored closely when IV insulin is given for DKA?
- AInsulin breaks down potassium in the bloodstream
- BInsulin has no effect on potassium in DKA
- CInsulin makes the kidneys retain potassium, so the level will rise
- DInsulin moves potassium into cells, so the level can fall quickly
12.Med-surg: neuro, endocrine & renalHard
A patient with myasthenia gravis is admitted with pneumonia. Which newly prescribed antibiotic should the nurse question?
- ACeftriaxone
- BGentamicin
- CAmoxicillin
- DBenzylpenicillin
13.Med-surg: GI, perioperative & oncologyMedium
Which nursing intervention best reduces preoperative anxiety?
- AKeeping family members away until after surgery
- BTelling the patient that there is nothing to worry about
- CAvoiding talking about the operation at all
- DExplaining what will happen and answering questions
14.Med-surg: GI, perioperative & oncologyHard
A 62-year-old with known reflux reports burning central chest pain with sweating and breathlessness that began while walking. What should the nurse do first?
- ARecord a 12-lead ECG and escalate as possible cardiac pain
- BBook a routine endoscopy for later in the week
- CAdvise the patient to avoid spicy food at future meals
- DGive an antacid and reassess the pain in an hour
3Solutions
1.Prioritization & delegation
Answer: C · Thank the assistant, make sure the task is done safely and arrange training
Why this is the answer
A delegate should refuse a task they are not competent to do. The nurse makes sure the task is done safely now and arranges training for the future. Forcing the task or leaving it undone puts the patient at risk.
C · Thank the assistant, make sure the task is done safely and arrange training
2.Prioritization & delegation
Answer: B · Check the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
Why this is the answer
A falling SpO₂ is a possible breathing problem and comes first. Insulin must be matched to the meal, routine medications have a time window, and documentation such as care plans comes last.
B · Check the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
3.Infection control & patient safety
Answer: B · Oral syringes do not fit IV lines, preventing wrong-route errors
Why this is the answer
Oral and enteral syringes have connectors that do not fit IV ports, so an oral liquid cannot be injected into a vein by mistake. Wrong-route errors with oral liquids have been fatal.
B · Oral syringes do not fit IV lines, preventing wrong-route errors
4.Infection control & patient safety
Answer: B · Alert staff and security at once, following the missing-patient procedure
Why this is the answer
A missing vulnerable patient is an emergency. The nurse immediately activates the facility’s missing-patient procedure so a search starts, and the provider and family are informed per policy.
B · Alert staff and security at once, following the missing-patient procedure
5.Lab values & electrolytes
Answer: C · Potassium and creatinine
Why this is the answer
ACE inhibitors reduce aldosterone, so potassium can rise, and they lower the filtration pressure in the kidney, so creatinine can rise. Both are checked before and soon after starting or increasing the dose.Checked against: Hyperkalemia · StatPearls (NCBI Bookshelf) (2025)
C · Potassium and creatinine
6.Lab values & electrolytes
Answer: D · Ferritin and transferrin saturation
Why this is the answer
Iron deficiency is the most common reason for a poor response to erythropoiesis-stimulating agents, because the marrow needs iron to make hemoglobin. Ferritin and transferrin saturation are checked, and IV iron is often given in dialysis patients. Infection and inflammation can also blunt the response.Checked against: Anemia of Chronic Kidney Disease · StatPearls (NCBI Bookshelf) (2024); Erythropoietin Stimulating Agents · StatPearls (NCBI Bookshelf) (2024)
D · Ferritin and transferrin saturation
7.Clinical nursing
Answer: D · Protect the head, time the seizure and do not put anything in the mouth
Why this is the answer
Remove nearby hazards, cushion the head, note the time and do not restrain or put objects in the mouth. Once jerking stops, place the patient in the recovery position and check the airway.
D · Protect the head, time the seizure and do not put anything in the mouth
8.Clinical nursing
Answer: B · Refeeding syndrome
Why this is the answer
Refeeding syndrome results from rapid shifts of phosphate, potassium and magnesium into cells when feeding resumes. High-risk patients start slowly with electrolyte monitoring and thiamine.
9.Med-surg: cardiovascular & respiratory
Answer: D · Some warning signs, such as a fast heartbeat, may be masked
Why this is the answer
Beta-blockers can blunt adrenergic symptoms of hypoglycaemia such as palpitations and tremor. Sweating usually remains. Patients should check their glucose if they feel unwell and know their other warning signs.
D · Some warning signs, such as a fast heartbeat, may be masked
10.Med-surg: cardiovascular & respiratory
Answer: D · Lying on the left side, with the bleeding lung down
Why this is the answer
In massive haemoptysis, the patient is positioned with the bleeding lung lowermost so blood does not flood the healthy lung. Oxygen, suction, IV access and urgent senior help follow. Treatment may include bronchial artery embolisation.
D · Lying on the left side, with the bleeding lung down
11.Med-surg: neuro, endocrine & renal
Answer: D · Insulin moves potassium into cells, so the level can fall quickly
Why this is the answer
Patients in DKA have a large total-body potassium deficit even if serum potassium is normal or high at first. Insulin shifts potassium into cells, which can cause dangerous hypokalaemia. Potassium is checked often and added to fluids as prescribed; if it is very low, insulin may be delayed until replacement has started.
D · Insulin moves potassium into cells, so the level can fall quickly
12.Med-surg: neuro, endocrine & renal
Answer: B · Gentamicin
Why this is the answer
Aminoglycosides such as gentamicin can impair neuromuscular transmission and trigger a myasthenic crisis. Fluoroquinolones, magnesium and some other drugs carry similar warnings. The nurse checks with the prescriber before giving it.
13.Med-surg: GI, perioperative & oncology
Answer: D · Explaining what will happen and answering questions
Why this is the answer
Clear information about what to expect, including pain control and recovery, reduces anxiety and can improve recovery. False reassurance does not address the patient's concerns.
D · Explaining what will happen and answering questions
14.Med-surg: GI, perioperative & oncology
Answer: A · Record a 12-lead ECG and escalate as possible cardiac pain
Why this is the answer
Cardiac pain can feel like heartburn. Exertional pain with sweating and breathlessness must be treated as possible acute coronary syndrome until excluded, so an ECG and urgent review come first.
A · Record a 12-lead ECG and escalate as possible cardiac pain
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