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 about storing insulin at home. Which statement shows a need for further teaching?
- A“I will not leave my insulin in a hot car.”
- B“I will keep my spare insulin in the freezer so it lasts longer.”
- C“I will keep unopened insulin in the fridge.”
- D“I will check the expiry date on the label before I use the vial.”
2.Prioritization & delegationHard
A patient on peritoneal dialysis has cloudy fluid draining out and abdominal pain. What does this most likely mean?
- AA normal finding at the end of each exchange
- BPeritonitis, which needs prompt reporting and a fluid sample
- CConstipation that will settle with a laxative later today or tomorrow
- DToo much fluid left in the abdomen after the drain
3.Infection control & patient safetyMedium
A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?
- AIncrease the feed rate to make up for the lost time
- BTape the tube in its new position and continue
- CStop the feeding until the tube position is checked
- DPush the tube back in and restart the feed
4.Infection control & patient safetyHard
A hospital will introduce new infusion pumps and wants to find out how the process could fail before any harm occurs. Which method fits best?
- ARoot cause analysis (RCA) of the new pumps
- BA morbidity and mortality meeting
- CAn incident report for each new pump
- DFailure mode and effects analysis (FMEA)
5.Lab values & electrolytesMedium
A patient’s white cell count is 16 × 10³/µL with a high proportion of immature neutrophils (bands). What does this most likely indicate?
- AIron-deficiency anemia
- BAn acute bacterial infection
- CA chronic viral illness only
- DA normal result
6.Lab values & electrolytesHard
A child with sickle cell disease and a recent viral illness is pale and tired. The hemoglobin has fallen sharply, and the reticulocyte count is very low. What is the most likely problem?
- AIron deficiency from a poor diet over months
- BAn aplastic crisis, often caused by parvovirus B19
- CA normal finding in sickle cell disease
- DA vaso-occlusive pain crisis in the bones
7.Clinical nursingMedium
A patient who injects drugs has a fever, a new heart murmur and small dark lines under the nails. What is the likely diagnosis?
- AInfective endocarditis
- BPericarditis
- CRheumatic fever
- DMyocardial infarction
8.Clinical nursingHard
Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?
- AIntramuscular injection into the anterolateral thigh
- BSubcutaneous injection into the upper arm
- CIntravenous bolus given by the nurse without monitoring
- DOral tablet dissolved under the tongue
9.Med-surg: cardiovascular & respiratoryMedium
A patient has had atrial fibrillation for more than 48 hours and is listed for elective cardioversion. Why is anticoagulation needed beforehand?
- AAnticoagulants convert AF back to sinus rhythm
- BAtrial clots may be dislodged when sinus rhythm returns
- CAnticoagulants make the shock less painful
- DAnticoagulants reduce the electrical energy needed for the shock
10.Med-surg: cardiovascular & respiratoryHard
A patient with a stab wound to the chest has a hole that sucks air with each breath. What is the immediate management?
- APack the wound tightly with gauze pushed deep into the chest
- BCover it with a vented chest seal or a dressing taped on three sides
- CSeal it completely with tape on all four sides and leave it alone
- DLeave it open and give a nebuliser
11.Med-surg: neuro, endocrine & renalMedium
Before a haemodialysis catheter is used, why is the lock solution withdrawn from each lumen?
- AIt contains concentrated anticoagulant
- BIt contains a strong antibiotic that must be kept
- CIt contains the patient's urine
- DIt contains air that keeps the line open
12.Med-surg: neuro, endocrine & renalHard
A man who takes tamsulosin for BPH is listed for cataract surgery. Which statement is correct?
- AIt should be swapped for oxybutynin the night before to protect the eye
- BThe dose should be doubled before surgery to prevent urinary retention
- CTamsulosin has no effects outside the urinary tract, so nothing changes
- DThe eye surgeon must be told, as it can cause floppy iris during surgery
13.Med-surg: GI, perioperative & oncologyMedium
How is an uncomplicated sigmoid volvulus often first treated?
- ADecompression with a flexible sigmoidoscope and flatus tube
- BA barium meal given by mouth to untwist the bowel slowly
- CHigh-dose laxatives taken by mouth
- DEating a large high-fibre meal
14.Med-surg: GI, perioperative & oncologyHard
A patient has an implanted port for chemotherapy. Which needle is used to access it?
- AA non-coring (Huber) needle
- BA wide-bore cannula with a steel stylet
- CAn intramuscular injection needle
- DA standard hollow needle used for venepuncture
3Solutions
1.Prioritization & delegation
Answer: B · “I will keep my spare insulin in the freezer so it lasts longer.”
Why this is the answer
Freezing damages insulin, and frozen insulin should not be used. Unopened insulin is kept in the fridge, and heat and expired products are avoided.
B · “I will keep my spare insulin in the freezer so it lasts longer.”
2.Prioritization & delegation
Answer: B · Peritonitis, which needs prompt reporting and a fluid sample
Why this is the answer
Cloudy effluent with abdominal pain is a classic sign of peritonitis, a serious complication of peritoneal dialysis. The nurse reports it and sends a sample as prescribed so antibiotics can start.
B · Peritonitis, which needs prompt reporting and a fluid sample
3.Infection control & patient safety
Answer: C · Stop the feeding until the tube position is checked
Why this is the answer
A displaced tube may now sit in the esophagus or airway. The feeding is stopped and the tube is not pushed back blindly. Its position is checked according to policy, or it is replaced.
C · Stop the feeding until the tube position is checked
4.Infection control & patient safety
Answer: D · Failure mode and effects analysis (FMEA)
Why this is the answer
FMEA is a proactive method that looks at each step of a process, asks how it could fail and what the effect would be, and changes the process in advance. Root cause analysis is used after an event has happened.
D · Failure mode and effects analysis (FMEA)
5.Lab values & electrolytes
Answer: B · An acute bacterial infection
Why this is the answer
A raised white count with more bands (a “left shift”) suggests that the marrow is responding to an acute bacterial infection or severe inflammation. The result is read together with the patient’s signs, such as fever.Checked against: Blood Differential · MedlinePlus (NIH) (2024)
B · An acute bacterial infection
6.Lab values & electrolytes
Answer: B · An aplastic crisis, often caused by parvovirus B19
Why this is the answer
Patients with sickle cell disease depend on a high reticulocyte count because their red cells live only a short time. Parvovirus B19 can stop red cell production for days, causing a rapid fall in hemoglobin with very low reticulocytes. Transfusion may be needed.Checked against: Reticulocyte Count · MedlinePlus (NIH) (2024)
B · An aplastic crisis, often caused by parvovirus B19
7.Clinical nursing
Answer: A · Infective endocarditis
Why this is the answer
Infective endocarditis causes fever and a new or changing murmur, sometimes with splinter haemorrhages. Several sets of blood cultures are taken before long-course IV antibiotics.
A · Infective endocarditis
8.Clinical nursing
Answer: A · Intramuscular injection into the anterolateral thigh
Why this is the answer
IM adrenaline into the outer thigh is absorbed quickly and is the first-line route. IV adrenaline is reserved for experienced specialists with full monitoring because of the risk of arrhythmias.
A · Intramuscular injection into the anterolateral thigh
9.Med-surg: cardiovascular & respiratory
Answer: B · Atrial clots may be dislodged when sinus rhythm returns
Why this is the answer
After 48 hours of AF, atrial thrombus may be present. Restoring organised contraction can expel it and cause a stroke. Patients are usually anticoagulated for at least three weeks before (or a transoesophageal echo excludes clot) and for at least four weeks afterwards.
B · Atrial clots may be dislodged when sinus rhythm returns
10.Med-surg: cardiovascular & respiratory
Answer: B · Cover it with a vented chest seal or a dressing taped on three sides
Why this is the answer
An open (sucking) chest wound lets air enter the pleural space. A vented chest seal or a dressing taped on three sides acts as a flap valve, letting air out but not in. A fully sealed dressing can cause a tension pneumothorax. A chest drain is placed away from the wound.
B · Cover it with a vented chest seal or a dressing taped on three sides
11.Med-surg: neuro, endocrine & renal
Answer: A · It contains concentrated anticoagulant
Why this is the answer
Dialysis catheter lumens are filled with a concentrated heparin or citrate lock. If it is flushed into the patient, it can cause bleeding or other effects. Catheters are usually accessed only by trained staff.
A · It contains concentrated anticoagulant
12.Med-surg: neuro, endocrine & renal
Answer: D · The eye surgeon must be told, as it can cause floppy iris during surgery
Why this is the answer
Tamsulosin blocks alpha-1A receptors in the iris dilator muscle as well as in the prostate, which can cause intraoperative floppy iris syndrome during cataract surgery. The effect can persist after the drug is stopped, so the surgeon must know in advance to plan the operation. Whether to pause it is a decision for the team.
D · The eye surgeon must be told, as it can cause floppy iris during surgery
13.Med-surg: GI, perioperative & oncology
Answer: A · Decompression with a flexible sigmoidoscope and flatus tube
Why this is the answer
Endoscopic decompression often untwists a sigmoid volvulus. Recurrence is common, so elective surgery may follow. Signs of ischaemia or perforation need emergency surgery.
A · Decompression with a flexible sigmoidoscope and flatus tube
14.Med-surg: GI, perioperative & oncology
Answer: A · A non-coring (Huber) needle
Why this is the answer
Implanted ports have a silicone septum that reseals after access with a non-coring needle. Aseptic technique, checking blood return before use and flushing according to policy keep the device working safely.
A · A non-coring (Huber) needle
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