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 is raising his voice, pacing and clenching his fists. What should the nurse do first?
- ATurn away and ignore the behavior
- BApply physical restraints at once
- CStand very close to him and tell him firmly and loudly to sit down and be quiet
- DSpeak calmly, keep a safe distance and invite him to talk about what is wrong
2.Prioritization & delegationHard
A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?
- AStop delegating any tasks to the assistant for the rest of the year
- BSay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret
- CTalk to the assistant privately, restate what must be reported and follow up closely
- DComplain about the assistant to the patients during care
3.Infection control & patient safetyMedium
A nurse finds a used needle in a patient’s bed linen. What should the nurse do?
- ARecap it with two hands before throwing it away
- BFold it into the linen and send it to the laundry
- CPick it up by the hub or with forceps, put it in a sharps container and report it
- DLeave it where it is for the housekeeping staff to remove later in the day
4.Infection control & patient safetyHard
A nurse teaches a patient who has had a splenectomy. Which statement shows a need for further teaching?
- A“Now that my spleen is out, a fever is nothing to worry about.”
- B“I will get medical help quickly if I get a high temperature.”
- C“I will tell all of my health care providers that I have no spleen.”
- D“I will keep my vaccinations up to date.”
5.Lab values & electrolytesMedium
A patient has a calcium of 11.8 mg/dL (2.95 mmol/L) from bone metastases. Which nursing measure is appropriate?
- AEncourage bed rest and limit oral fluids
- BEncourage fluids and mobility as tolerated
- CGive calcium carbonate antacids for nausea
- DOffer extra milk and cheese at each meal
6.Lab values & electrolytesHard
The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?
- A"I'll keep the tablets out of reach of the children"
- B"I can take it with orange juice to help absorption"
- C"My stools may look darker while I take the tablets"
- D"I'll take my iron tablet with a big glass of milk"
7.Clinical nursingMedium
What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?
- ATake it with a large glass of milk to protect the stomach lining
- BSwallow the spray rather than leaving it under the tongue
- CUse it only after the pain has lasted over an hour, with the patient lying flat
- DSit down before using it, as it can cause dizziness and low blood pressure
8.Clinical nursingHard
A nurse realises she has given a patient a medicine prescribed for another patient. What should she do first?
- ACheck the patient's condition and inform the doctor
- BWait to see whether any side effects develop
- CAsk a colleague not to mention it
- DGive the patient's own medicine as well to balance it
9.Med-surg: cardiovascular & respiratoryMedium
How does digoxin help a patient with atrial fibrillation and heart failure?
- AIt speeds conduction through the AV node to the ventricles
- BIt lowers potassium to stabilise the heart
- CIt slows AV node conduction and increases contractility
- DIt dissolves clots that have formed in the left atrium
10.Med-surg: cardiovascular & respiratoryHard
A patient with squamous cell lung cancer becomes confused, thirsty and constipated, with abdominal pain. Which electrolyte disturbance is most likely?
- AHypokalaemia
- BHypercalcaemia
- CHyponatraemia
- DHypomagnesaemia
11.Med-surg: neuro, endocrine & renalMedium
A patient's potassium stays low despite replacement. Which other level should be checked?
- ABilirubin
- BMagnesium
- CAmylase
- DFerritin
12.Med-surg: neuro, endocrine & renalHard
A patient has had a high sodium of 160 mmol/L for several days. Why must it be corrected slowly?
- ARapid correction raises the blood glucose
- BThe sodium will rise again if corrected quickly
- CRapid correction can cause brain swelling
- DRapid correction causes kidney stones
13.Med-surg: GI, perioperative & oncologyMedium
Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?
- AMild tiredness after a busy day
- BNew diarrhoea or abdominal pain
- CA small bruise after a knock
- DSlight hair thinning over months
14.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient with chronic pancreatitis. Which statement shows a need for further teaching?
- A"I'll take my enzyme capsules at bedtime."
- B"Oily, floating stools may mean my dose needs changing."
- C"I should not drink any alcohol."
- D"I'll report increased thirst or passing urine more often."
3Solutions
1.Prioritization & delegation
Answer: D · Speak calmly, keep a safe distance and invite him to talk about what is wrong
Why this is the answer
Early verbal de-escalation, with a calm voice and a safe distance, is the first approach for rising agitation. Restraint is a last resort, and crowding the patient can make things worse.
D · Speak calmly, keep a safe distance and invite him to talk about what is wrong
2.Prioritization & delegation
Answer: C · Talk to the assistant privately, restate what must be reported and follow up closely
Why this is the answer
The RN gives direct, private feedback, restates the reporting limits and increases supervision. If the problem continues, it is escalated to the manager according to policy.
C · Talk to the assistant privately, restate what must be reported and follow up closely
3.Infection control & patient safety
Answer: C · Pick it up by the hub or with forceps, put it in a sharps container and report it
Why this is the answer
A loose needle is a hazard to everyone who handles the linen. The nurse disposes of it safely without recapping, using an instrument if needed, and reports the incident so the cause can be addressed.
C · Pick it up by the hub or with forceps, put it in a sharps container and report it
4.Infection control & patient safety
Answer: A · “Now that my spleen is out, a fever is nothing to worry about.”
Why this is the answer
People without a spleen are at risk of overwhelming infection, especially from encapsulated bacteria. Fever needs prompt medical assessment, and vaccines are kept up to date.
A · “Now that my spleen is out, a fever is nothing to worry about.”
5.Lab values & electrolytes
Answer: B · Encourage fluids and mobility as tolerated
Why this is the answer
Hydration helps the kidneys excrete calcium and prevents stones, and weight-bearing mobility slows calcium loss from bone. Calcium-containing foods and antacids are not encouraged. The nurse also monitors for confusion, constipation and arrhythmias.Checked against: Hypercalcemia · MedlinePlus (NIH) (2026)
B · Encourage fluids and mobility as tolerated
6.Lab values & electrolytes
Answer: D · "I'll take my iron tablet with a big glass of milk"
Why this is the answer
Calcium in milk, as well as antacids and tea, reduces iron absorption, so iron should not be taken with them. Vitamin C improves absorption, dark stools are expected, and iron overdose is a serious poisoning risk in young children.Checked against: Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025); Iron in diet - Medical Encyclopedia · MedlinePlus (NIH) (2025)
D · "I'll take my iron tablet with a big glass of milk"
7.Clinical nursing
Answer: D · Sit down before using it, as it can cause dizziness and low blood pressure
Why this is the answer
GTN causes vasodilation, which can lead to headache, flushing, dizziness and hypotension. Patients should sit, and seek emergency help if the pain does not settle after the advised doses.
D · Sit down before using it, as it can cause dizziness and low blood pressure
8.Clinical nursing
Answer: A · Check the patient's condition and inform the doctor
Why this is the answer
The first priority is the patient: assess them and inform the prescriber so that any treatment can be given. The error must then be documented, reported and discussed openly with the patient (open disclosure; in the UK, the statutory duty of candour).
A · Check the patient's condition and inform the doctor
9.Med-surg: cardiovascular & respiratory
Answer: C · It slows AV node conduction and increases contractility
Why this is the answer
Digoxin inhibits the Na⁺/K⁺-ATPase, raising intracellular calcium and contractility, and increases vagal tone, slowing AV conduction and the ventricular rate. It controls symptoms but does not reduce stroke risk, so anticoagulation is still needed in AF.
C · It slows AV node conduction and increases contractility
10.Med-surg: cardiovascular & respiratory
Answer: B · Hypercalcaemia
Why this is the answer
Squamous cell lung cancer can secrete PTH-related protein, and bone metastases can release calcium. Hypercalcaemia causes confusion, thirst, polyuria, constipation, abdominal pain and arrhythmias ("bones, stones, groans and psychiatric overtones"). Treatment includes IV fluids and bisphosphonates.
11.Med-surg: neuro, endocrine & renal
Answer: B · Magnesium
Why this is the answer
Hypomagnesaemia increases potassium loss in the urine and makes hypokalaemia hard to correct. Magnesium is checked and replaced as well.
12.Med-surg: neuro, endocrine & renal
Answer: C · Rapid correction can cause brain swelling
Why this is the answer
In chronic hypernatraemia, brain cells adapt by holding extra solutes. If the sodium falls too quickly, water rushes into the cells and causes cerebral oedema and seizures. Correction is gradual, with regular sodium checks.
C · Rapid correction can cause brain swelling
13.Med-surg: GI, perioperative & oncology
Answer: B · New diarrhoea or abdominal pain
Why this is the answer
Checkpoint inhibitors can cause immune-mediated colitis, pneumonitis, hepatitis, skin reactions and endocrine problems. Early reporting allows grading and treatment, often with corticosteroids.
B · New diarrhoea or abdominal pain
14.Med-surg: GI, perioperative & oncology
Answer: A · "I'll take my enzyme capsules at bedtime."
Why this is the answer
Pancreatic enzymes must be taken with meals and snacks to digest them. Alcohol must be avoided, steatorrhoea suggests under-replacement, and thirst or polyuria can signal diabetes from loss of islet cells.
A · "I'll take my enzyme capsules at bedtime."
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