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 medical unit tells the nurse he has a plan to end his life and has saved tablets at home. What is the priority action?
- AArrange a psychiatry appointment for next week
- BReassure him that things usually look better in the morning after some sleep
- CEnsure constant observation and remove anything he could use to harm himself
- DAsk him to promise he will not harm himself
2.Prioritization & delegationHard
An infant is choking and cannot cry or breathe. Which technique is correct?
- AAbdominal thrusts, as in adults
- BBack blows and chest thrusts
- CA blind finger sweep of the mouth
- DHolding the infant upside down by the feet
3.Infection control & patient safetyMedium
An older adult has trouble getting in and out of the bath. Which measures make bathing safer?
- ABath oil to help the person slide in and out
- BA loose rug beside the tub to stand on
- CLocking the bathroom door for privacy
- DA shower chair, grab bars and a non-slip mat
4.Infection control & patient safetyHard
A patient is admitted with suspected pneumonic plague after a possible bioterrorism release. Which precautions are used?
- AAirborne precautions
- BStandard precautions only
- CContact precautions only
- DDroplet precautions
5.Lab values & electrolytesMedium
A nurse has a needlestick injury from a patient with unknown HIV status. Which test is usually done for the nurse as soon as possible?
- AA baseline HIV test
- BA thyroid panel test
- CA sweat chloride test
- DA serum lipase test
6.Lab values & electrolytesHard
A patient has a positive hepatitis C antibody (anti-HCV) test. What is the most appropriate next step?
- ATest for HCV RNA to find out whether infection is current
- BGive hepatitis C vaccine to prevent further infection
- CTell the patient they definitely have chronic hepatitis C
- DRepeat the antibody test, as a positive test is always false
7.Clinical nursingMedium
What should a patient starting oral iron tablets be told?
- AThey must take the tablets with strong tea
- BTheir stools may turn dark or black
- CTheir urine will turn bright green
- DThe tablets will cause weight loss
8.Clinical nursingHard
A patient who speaks little English needs to give consent for a procedure. Their 14-year-old child offers to interpret. What is the best action?
- AArrange a professional interpreter
- BUse gestures and proceed
- CLet the child interpret to save time
- DAsk the patient to sign the form without explanation
9.Med-surg: cardiovascular & respiratoryMedium
A patient has chest pain at rest in the early morning with brief ST elevation that resolves. Coronary arteries are later found to be clear. Which condition is most likely?
- AVasospastic (Prinzmetal) angina
- BAcute pericarditis
- CAortic stenosis
- DStable exertional angina from a fixed plaque
10.Med-surg: cardiovascular & respiratoryHard
A patient with severe aortic stenosis is prescribed glyceryl trinitrate (nitroglycerin) for chest pain. Why should the nurse use particular caution?
- AVasodilators can cause a severe fall in BP with a fixed outflow obstruction
- BThere is no reason for caution, because GTN acts only on the coronary arteries
- CGTN makes the narrowed aortic valve tighten further within a few minutes
- DGTN raises the blood pressure dangerously in aortic stenosis
11.Med-surg: neuro, endocrine & renalMedium
After transsphenoidal pituitary surgery, which advice should the patient follow?
- ALie completely flat for at least a week after surgery
- BAvoid blowing the nose, straining and bending forward
- CBlow the nose often to clear any clots
- DDrink through a straw to keep the nose clean
12.Med-surg: neuro, endocrine & renalHard
Which of these patients with acute ischaemic stroke is least likely to be eligible for IV thrombolysis?
- AA patient who had major abdominal surgery five days ago
- BA patient whose CT scan shows no sign of any intracranial bleeding
- CA patient whose blood pressure is 170/95 mmHg
- DA patient whose symptoms began 90 minutes ago
13.Med-surg: GI, perioperative & oncologyMedium
A nasogastric feeding tube appears blocked. What is usually the first step?
- APush the guidewire back in to clear it
- BUse a small 5 mL syringe with firm pressure
- CCut the end of the tube to release the blockage inside it
- DFlush gently with warm water in a 50 mL enteral syringe
14.Med-surg: GI, perioperative & oncologyHard
A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?
- ADo the dressing quickly and give analgesia afterwards
- BChange the dressing less often than the plan says
- CGive analgesia timed so it works during the dressing change
- DAvoid analgesia so the patient can report any problems during the change
3Solutions
1.Prioritization & delegation
Answer: C · Ensure constant observation and remove anything he could use to harm himself
Why this is the answer
A patient with a plan and means is at high risk. Safety comes first: constant observation, removal of means and urgent referral. A “no-harm promise” does not protect the patient.
C · Ensure constant observation and remove anything he could use to harm himself
2.Prioritization & delegation
Answer: B · Back blows and chest thrusts
Why this is the answer
For a choking infant, the nurse gives cycles of five back blows and five chest thrusts. Abdominal thrusts are not used in infants, and blind finger sweeps can push the object deeper.
B · Back blows and chest thrusts
3.Infection control & patient safety
Answer: D · A shower chair, grab bars and a non-slip mat
Why this is the answer
Shower chairs, grab bars and non-slip surfaces reduce slips and falls. Bath oils make surfaces slippery, and a locked door delays help if the person falls.
D · A shower chair, grab bars and a non-slip mat
4.Infection control & patient safety
Answer: D · Droplet precautions
Why this is the answer
Pneumonic plague spreads from person to person by respiratory droplets, so droplet precautions are used until the patient has had effective antibiotics for the period set by policy. Bubonic plague without lung involvement needs standard precautions.
5.Lab values & electrolytes
Answer: A · A baseline HIV test
Why this is the answer
After an occupational exposure, the wound is washed and the incident is reported at once. Baseline tests for HIV, hepatitis B and hepatitis C are taken, and post-exposure prophylaxis is started as soon as possible if indicated, ideally within hours.
6.Lab values & electrolytes
Answer: A · Test for HCV RNA to find out whether infection is current
Why this is the answer
Anti-HCV shows exposure, but some people clear the virus and keep antibodies. An HCV RNA test shows whether the infection is current. There is no vaccine for hepatitis C, but antiviral treatment can cure most infections.
A · Test for HCV RNA to find out whether infection is current
7.Clinical nursing
Answer: B · Their stools may turn dark or black
Why this is the answer
Oral iron commonly darkens the stool and can cause constipation or stomach upset. Tea and antacids reduce absorption, while vitamin C may increase it.
B · Their stools may turn dark or black
8.Clinical nursing
Answer: A · Arrange a professional interpreter
Why this is the answer
Professional interpreters provide accurate, impartial translation and protect confidentiality. Children and family members should not be used for important clinical discussions such as consent.
A · Arrange a professional interpreter
9.Med-surg: cardiovascular & respiratory
Answer: A · Vasospastic (Prinzmetal) angina
Why this is the answer
Vasospastic angina is caused by temporary coronary artery spasm, often at rest or at night, with transient ST elevation. It responds to calcium channel blockers and nitrates. Triggers include smoking, cold and cocaine.
A · Vasospastic (Prinzmetal) angina
10.Med-surg: cardiovascular & respiratory
Answer: A · Vasodilators can cause a severe fall in BP with a fixed outflow obstruction
Why this is the answer
In severe aortic stenosis, cardiac output is fixed by the narrow valve. Vasodilators lower preload and afterload, and the heart cannot compensate, so the blood pressure can fall sharply and cause syncope. They are used with care and close monitoring.
A · Vasodilators can cause a severe fall in BP with a fixed outflow obstruction
11.Med-surg: neuro, endocrine & renal
Answer: B · Avoid blowing the nose, straining and bending forward
Why this is the answer
Raised pressure in the head can open the repair and cause a CSF leak. Patients avoid nose blowing, straining, coughing hard and bending forward, and sneeze with the mouth open. Straws may also be avoided.
B · Avoid blowing the nose, straining and bending forward
12.Med-surg: neuro, endocrine & renal
Answer: A · A patient who had major abdominal surgery five days ago
Why this is the answer
Recent major surgery (within roughly 14 days in many guidelines) greatly increases the bleeding risk and is a contraindication to thrombolysis. Onset within 4.5 hours, a blood pressure below 185/110 mmHg and a CT without haemorrhage are conditions that permit it.
A · A patient who had major abdominal surgery five days ago
13.Med-surg: GI, perioperative & oncology
Answer: D · Flush gently with warm water in a 50 mL enteral syringe
Why this is the answer
Gentle flushing with warm water using a 50 mL enteral syringe may clear a blockage. Small syringes and force can rupture the tube, and reinserting a guidewire can perforate the oesophagus.
D · Flush gently with warm water in a 50 mL enteral syringe
14.Med-surg: GI, perioperative & oncology
Answer: C · Give analgesia timed so it works during the dressing change
Why this is the answer
Procedural pain is best managed by giving analgesia so its peak effect matches the procedure. Non-adherent dressings, soaking adherent dressings and allowing the patient to call pauses also help.
C · Give analgesia timed so it works during the dressing change
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