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 levothyroxine. Which statement shows a need for further teaching?
- A“I will take it at the same time each morning.”
- B“I will take it on an empty stomach with a glass of water.”
- C“I will keep taking it even when I feel well.”
- D“I will take it at breakfast with my calcium tablet.”
2.Prioritization & delegationHard
After handover on a medical unit, which patient should the nurse see first?
- ADay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now
- BDeep vein thrombosis on a heparin infusion, aPTT in the target range
- CPneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
- DNew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
3.Infection control & patient safetyMedium
Which practice reduces back strain when a nurse moves a patient or heavy object?
- AHold the load at arm’s length to keep it steady
- BStand with the feet close together for balance
- CKeep the load close to the body and avoid twisting
- DBend at the waist and keep both knees straight
4.Infection control & patient safetyHard
Shortly after a patient falls, the team holds a brief “post-fall huddle”. What is its main purpose?
- ATo decide which staff member was to blame for the fall
- BTo complete the patient’s discharge paperwork
- CTo find out quickly why the fall happened and change the care plan to prevent another
- DTo agree on what the team will tell the patient’s lawyer and the family
5.Lab values & electrolytesMedium
Which blood collection practice helps prevent hemolysis of the sample?
- AForcing blood quickly through a needle into the tube
- BLeaving the tourniquet on for at least 3 minutes
- CUsing the smallest needle available for every patient
- DGently inverting the tubes instead of shaking them
6.Lab values & electrolytesHard
A patient with a calcium of 6.8 mg/dL (1.7 mmol/L) suddenly develops noisy breathing and a hoarse voice. What does this suggest?
- AAnxiety about the blood results, which needs calm reassurance
- BA normal response that will pass without treatment
- CLaryngospasm, an emergency needing urgent help and IV calcium
- DA common cold that started this morning
7.Clinical nursingMedium
Which observation is most important after giving a patient a first dose of a new antibiotic intravenously?
- ATheir appetite at the next meal
- BHow much they walk that day
- CSigns of an allergic reaction such as rash, wheeze or swelling
- DWhether their hair loss increases
8.Clinical nursingHard
A nurse notices that a wrong dose of a drug was prepared but was caught before it was given. What should be done?
- AReport it as a near miss through the incident reporting system
- BTell only the patient's family
- CDiscipline the nurse who prepared it on the spot in front of colleagues
- DSay nothing, because no harm reached the patient
9.Med-surg: cardiovascular & respiratoryMedium
Two days after a myocardial infarction, a patient develops sudden breathlessness, crackles and a new loud systolic murmur. Which complication should be suspected?
- AA pulmonary embolism caused by prolonged bed rest
- BPapillary muscle rupture with acute mitral regurgitation
- CPost-infarction pericarditis causing a pericardial friction rub
- DA new episode of stable angina brought on by stress
10.Med-surg: cardiovascular & respiratoryHard
A patient on warfarin for atrial fibrillation has an INR of 8.5 but no bleeding. What is the most likely management?
- AGive IV protamine sulfate immediately to reverse it
- BWithhold warfarin, inform the prescriber and recheck the INR soon
- CGive prothrombin complex concentrate and a blood transfusion
- DContinue the usual dose and recheck the INR in a month
11.Med-surg: neuro, endocrine & renalMedium
A patient with primary adrenal insufficiency has a fever. What is the usual sick-day advice for steroid replacement?
- AKeep the usual dose and avoid drinking extra fluids for now
- BIncrease the glucocorticoid dose, often doubling it
- CStop the steroid until the fever has settled
- DHalve the dose to reduce the side effects
12.Med-surg: neuro, endocrine & renalHard
A patient is being assessed for brain death (brainstem death). Which condition must be excluded before testing?
- AEffects of sedative drugs or severe hypothermia
- BA history of high blood pressure
- CA previous episode of migraine
- DA haemoglobin of 110 g/L (11 g/dL)
13.Med-surg: GI, perioperative & oncologyMedium
Which advice has good evidence for reducing cancer-related fatigue?
- AAvoiding all daily activities
- BRegular light to moderate activity, such as walking
- CComplete bed rest for the whole course of treatment
- DDrinking several strong coffees every evening
14.Med-surg: GI, perioperative & oncologyHard
A patient with known oesophageal varices is vomiting large amounts of fresh blood. Which treatments should the nurse anticipate before endoscopy?
- ARapid saline infusion to a high blood pressure
- BAn urgent barium swallow before any drug treatment
- COctreotide or terlipressin, plus IV antibiotics, during resuscitation
- DOral NSAID for pain and a high-protein meal
3Solutions
1.Prioritization & delegation
Answer: D · “I will take it at breakfast with my calcium tablet.”
Why this is the answer
Levothyroxine is best absorbed on an empty stomach and is separated from calcium and iron by several hours. It is usually lifelong, so it is not stopped when the patient feels better.
D · “I will take it at breakfast with my calcium tablet.”
2.Prioritization & delegation
Answer: D · New atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
Why this is the answer
Rapid atrial fibrillation with hypotension and dizziness means the heart is not pumping enough blood; the patient is unstable. The other patients are within target or have predictable needs.
D · New atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
3.Infection control & patient safety
Answer: C · Keep the load close to the body and avoid twisting
Why this is the answer
Good body mechanics include a wide base of support, bending at the hips and knees, keeping the load close and turning with the feet instead of twisting the spine. Lifting aids are used whenever possible.
C · Keep the load close to the body and avoid twisting
4.Infection control & patient safety
Answer: C · To find out quickly why the fall happened and change the care plan to prevent another
Why this is the answer
A post-fall huddle brings the team together soon after the fall to identify causes such as toileting, medication or footwear and to update the plan. It supports a just culture rather than blame.
C · To find out quickly why the fall happened and change the care plan to prevent another
5.Lab values & electrolytes
Answer: D · Gently inverting the tubes instead of shaking them
Why this is the answer
Hemolysis falsely raises potassium and affects other results. It is reduced by gentle inversion of tubes, avoiding very small needles, avoiding strong suction or forcing blood through a needle, and keeping tourniquet time short.
D · Gently inverting the tubes instead of shaking them
6.Lab values & electrolytes
Answer: C · Laryngospasm, an emergency needing urgent help and IV calcium
Why this is the answer
Severe hypocalcemia can cause spasm of the larynx, which blocks the airway. The nurse calls for urgent help, supports the airway and prepares IV calcium gluconate as prescribed, with cardiac monitoring.Checked against: Hypocalcemia (StatPearls) · StatPearls (NCBI Bookshelf) (2026)
C · Laryngospasm, an emergency needing urgent help and IV calcium
7.Clinical nursing
Answer: C · Signs of an allergic reaction such as rash, wheeze or swelling
Why this is the answer
First doses carry a risk of anaphylaxis. Watch for rash, urticaria, swelling, wheeze, breathlessness and falling blood pressure.
C · Signs of an allergic reaction such as rash, wheeze or swelling
8.Clinical nursing
Answer: A · Report it as a near miss through the incident reporting system
Why this is the answer
Near misses are reported so that causes can be studied and systems improved. A just, open culture encourages reporting without blame.
A · Report it as a near miss through the incident reporting system
9.Med-surg: cardiovascular & respiratory
Answer: B · Papillary muscle rupture with acute mitral regurgitation
Why this is the answer
Rupture of a papillary muscle (or of the ventricular septum) after MI produces a new murmur and sudden heart failure or shock. This is a surgical emergency. Pericarditis causes pleuritic chest pain and a friction rub rather than acute pulmonary oedema with a new murmur.
B · Papillary muscle rupture with acute mitral regurgitation
10.Med-surg: cardiovascular & respiratory
Answer: B · Withhold warfarin, inform the prescriber and recheck the INR soon
Why this is the answer
A very high INR without bleeding is usually managed by withholding warfarin, informing the prescriber and repeating the INR. Low-dose oral vitamin K may also be prescribed depending on the INR and local protocol (UK guidance gives it above an INR of 8; US guidance mainly above 10 or with high bleeding risk). Prothrombin complex concentrate and IV vitamin K are used for major bleeding. Protamine reverses heparin. The reason for the rise (new drugs, illness, diet) should be explored.
B · Withhold warfarin, inform the prescriber and recheck the INR soon
11.Med-surg: neuro, endocrine & renal
Answer: B · Increase the glucocorticoid dose, often doubling it
Why this is the answer
During illness, people on steroid replacement need more glucocorticoid. Sick-day rules usually advise doubling the dose during fever and using emergency injectable hydrocortisone or seeking urgent care if they vomit and cannot keep tablets down, to prevent adrenal crisis.
B · Increase the glucocorticoid dose, often doubling it
12.Med-surg: neuro, endocrine & renal
Answer: A · Effects of sedative drugs or severe hypothermia
Why this is the answer
Before brain death (brainstem) testing, reversible causes of coma must be excluded, including sedatives and neuromuscular blockers, hypothermia, and severe metabolic or endocrine disturbance. Only then can absent reflexes be interpreted reliably.
A · Effects of sedative drugs or severe hypothermia
13.Med-surg: GI, perioperative & oncology
Answer: B · Regular light to moderate activity, such as walking
Why this is the answer
Exercise, matched to ability, reduces cancer-related fatigue. Pacing, prioritising activities, sleep routines and treating causes such as anaemia or depression also help.
B · Regular light to moderate activity, such as walking
14.Med-surg: GI, perioperative & oncology
Answer: C · Octreotide or terlipressin, plus IV antibiotics, during resuscitation
Why this is the answer
In suspected variceal bleeding, a vasoactive drug (octreotide in the US, or terlipressin where it is licensed) reduces portal pressure, and prophylactic antibiotics such as ceftriaxone reduce infection and mortality in cirrhosis. Resuscitation is cautious to avoid raising portal pressure. Endoscopic band ligation is the definitive treatment.
C · Octreotide or terlipressin, plus IV antibiotics, during resuscitation
This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.