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 patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?
- AStop the heparin infusion and inform the provider
- BGive a dose of vitamin K by mouth
- COffer an iron-rich meal to replace the lost blood
- DCheck the pump rate and leave the infusion running
2.Prioritization & delegationHard
A toddler with tetralogy of Fallot becomes very blue and breathless while crying. What should the nurse do first?
- AEncourage the child to keep crying to open the lungs
- BGive a large drink of water to calm the child
- CLay the child flat on their back
- DPlace the child in a knee-to-chest position
3.Infection control & patient safetyMedium
A patient has orthostatic hypotension. Which teaching helps to prevent falls?
- AAvoid drinking fluids in the morning to reduce trips to the toilet
- BGet out of bed quickly so the dizziness passes sooner
- CStand up straight after a hot shower to increase blood flow
- DSit on the edge of the bed for a short time before standing up slowly
4.Infection control & patient safetyHard
According to the “Swiss cheese” model of error, why do errors reach patients?
- APatients often do not follow their care instructions
- BOne careless person makes a mistake that no system could stop
- CTechnology fails more often than people do
- DWeaknesses in several layers of defense line up at the same time
5.Lab values & electrolytesMedium
A patient has an absolute neutrophil count of 0.4 × 10³/µL. Which measure is appropriate?
- AStrict hand hygiene, temperature checks and no visitors with infections
- BBringing fresh flowers into the room to lift the patient’s mood
- CSharing a room with another patient who is being treated for pneumonia
- DTaking temperatures rectally because readings are more accurate
6.Lab values & electrolytesHard
A patient with a round face, central weight gain and purple stretch marks has a glucose of 210 mg/dL (11.7 mmol/L) and a potassium of 3.1 mEq/L. Which condition fits best?
- AAdrenal insufficiency
- BCushing syndrome
- CDiabetes insipidus
- DHypothyroidism
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 healthcare assistant reports four observations. Which one needs the nurse's immediate action?
- A"Mrs Jones would like a cup of tea and her glasses cleaned."
- B"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
- C"Mr Chen's blood pressure is 128/80 as usual."
- D"Ms Ali has walked to the bathroom on her own."
9.Med-surg: cardiovascular & respiratoryMedium
Which position is usually best for the legs of a patient with chronic venous insufficiency and ankle swelling?
- ACrossed at the knees while sitting
- BKept still in a standing position for long periods
- CRaised above the level of the heart when resting
- DHanging down over the side of the bed
10.Med-surg: cardiovascular & respiratoryHard
A patient with COPD is breathless with SpO₂ 84% on air. A blood gas shows pH 7.30 and a raised PaCO₂ despite optimal medical treatment. Which treatment is likely to be considered?
- AIV sedation to slow the breathing rate
- BNon-invasive ventilation (NIV)
- CHigh-concentration oxygen by non-rebreather mask
- DStopping the nebulised bronchodilators
11.Med-surg: neuro, endocrine & renalMedium
How should peritoneal dialysis fluid be warmed before use?
- AIn a bowl of hot tap water
- BIn a dedicated dry-heat warmer
- CIn a microwave oven
- DIt should be used cold from the fridge
12.Med-surg: neuro, endocrine & renalHard
Why may nitrofurantoin be avoided in an older patient with significantly reduced kidney function?
- AIt cannot be taken with food in kidney disease
- BIt turns the urine red in kidney disease
- CIt works less well and is more likely to be toxic
- DIt cures kidney disease too quickly
13.Med-surg: GI, perioperative & oncologyMedium
Why does a patient need lifelong vitamin B12 injections after total gastrectomy?
- AThe liver can no longer store any vitamins
- BThe small bowel stops absorbing all nutrients
- CIntrinsic factor from the stomach is no longer made
- DVitamin B12 is lost in the urine after the surgery
14.Med-surg: GI, perioperative & oncologyHard
A patient on modified-release morphine for cancer pain has needed four breakthrough doses every day for several days. What should the nurse do?
- AStop the breakthrough doses to reduce opioid use
- BReport it, as the regular background dose may need review
- CGive all breakthrough doses at the same time
- DTell the patient to put up with the pain between doses
3Solutions
1.Prioritization & delegation
Answer: A · Stop the heparin infusion and inform the provider
Why this is the answer
Black, tarry stools suggest upper GI bleeding, and a high aPTT shows too much anticoagulation. The nurse stops the heparin, checks vital signs and informs the provider, who may prescribe protamine sulfate. Vitamin K reverses warfarin, not heparin.
A · Stop the heparin infusion and inform the provider
2.Prioritization & delegation
Answer: D · Place the child in a knee-to-chest position
Why this is the answer
In a hypercyanotic (“tet”) spell, the knee-chest position raises systemic vascular resistance and sends more blood to the lungs. Oxygen and prescribed medication follow.
D · Place the child in a knee-to-chest position
3.Infection control & patient safety
Answer: D · Sit on the edge of the bed for a short time before standing up slowly
Why this is the answer
Changing position slowly, dangling the legs first and getting up with help give the circulation time to adjust. Rapid standing, heat and dehydration make orthostatic hypotension worse.
D · Sit on the edge of the bed for a short time before standing up slowly
4.Infection control & patient safety
Answer: D · Weaknesses in several layers of defense line up at the same time
Why this is the answer
Reason’s Swiss cheese model shows that each safety layer, such as prescribing, dispensing, checking and scanning, has weaknesses. Harm happens when the holes in several layers line up, so safety improvement focuses on strengthening the system.
D · Weaknesses in several layers of defense line up at the same time
5.Lab values & electrolytes
Answer: A · Strict hand hygiene, temperature checks and no visitors with infections
Why this is the answer
Severe neutropenia carries a high risk of infection. Hand hygiene, early recognition of fever and protection from sources of infection are key. Flowers can carry organisms, rectal procedures can injure the mucosa, and a roommate with pneumonia is an infection risk.Checked against: Low white blood cell count and cancer · MedlinePlus (NIH) (2025)
A · Strict hand hygiene, temperature checks and no visitors with infections
6.Lab values & electrolytes
Answer: B · Cushing syndrome
Why this is the answer
Excess cortisol raises glucose, causes central obesity, a round face and purple striae, and has some mineralocorticoid effect that lowers potassium. Adrenal insufficiency causes low glucose and high potassium.Checked against: Hypercortisolism (Cushing Syndrome) · StatPearls (NCBI Bookshelf) (2025); Hypokalemia · StatPearls (NCBI Bookshelf) (2025)
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.
8.Clinical nursing
Answer: B · "Mr Patel's breathing rate is 8 a minute and he's hard to wake."
Why this is the answer
A low respiratory rate with reduced consciousness suggests respiratory depression, for example from opioids. It needs immediate assessment and escalation.
B · "Mr Patel's breathing rate is 8 a minute and he's hard to wake."
9.Med-surg: cardiovascular & respiratory
Answer: C · Raised above the level of the heart when resting
Why this is the answer
Elevating the legs above heart level reduces venous pressure and oedema. Compression therapy, walking and avoiding long periods of standing also help. By contrast, patients with arterial disease often find that lowering the legs eases pain.
C · Raised above the level of the heart when resting
10.Med-surg: cardiovascular & respiratory
Answer: B · Non-invasive ventilation (NIV)
Why this is the answer
In an acute COPD exacerbation with respiratory acidosis (pH < 7.35 and raised PaCO₂) persisting despite optimal medical therapy, NIV reduces mortality and the need for intubation. Controlled oxygen continues with a target of 88–92%. Uncontrolled high-flow oxygen and sedatives can worsen CO₂ retention.
B · Non-invasive ventilation (NIV)
11.Med-surg: neuro, endocrine & renal
Answer: B · In a dedicated dry-heat warmer
Why this is the answer
Warming dialysate to body temperature improves comfort. A microwave heats unevenly and can create hot spots; soaking can contaminate the ports. Manufacturer-approved dry heat warmers are used.
B · In a dedicated dry-heat warmer
12.Med-surg: neuro, endocrine & renal
Answer: C · It works less well and is more likely to be toxic
Why this is the answer
Nitrofurantoin is concentrated in the urine. With poor kidney function, urine levels fall, so it works less well, and blood levels rise, increasing side effects such as neuropathy. Another antibiotic is usually chosen.
C · It works less well and is more likely to be toxic
13.Med-surg: GI, perioperative & oncology
Answer: C · Intrinsic factor from the stomach is no longer made
Why this is the answer
Parietal cells of the stomach make intrinsic factor, which is needed for B12 absorption in the terminal ileum. Without it, pernicious-type anaemia and neuropathy develop unless B12 is given by injection.
C · Intrinsic factor from the stomach is no longer made
14.Med-surg: GI, perioperative & oncology
Answer: B · Report it, as the regular background dose may need review
Why this is the answer
Regular need for breakthrough doses usually means the background analgesia is inadequate. The prescriber reviews and may adjust the regular dose, while side effects such as sedation are monitored.
B · Report it, as the regular background dose may need review
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