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 with COPD pursed-lip breathing. Which statement shows a need for further teaching?
- A“I will breathe in slowly through my nose.”
- B“I will make my breath out about twice as long as my breath in.”
- C“I will breathe in through my mouth and out quickly through my nose.”
- D“I will breathe out slowly through pursed lips.”
2.Prioritization & delegationHard
A nurse returns to the station to find four messages. Which one is answered first?
- AA family member wants an update on their father’s progress
- BA colleague asks to swap shifts with them next week because of a family wedding
- CThe pharmacy asks when the next delivery should be scheduled
- DThe laboratory is calling with a critical potassium result of 2.6 mEq/L
3.Infection control & patient safetyMedium
How should the urethral meatus be cared for in a patient with an indwelling urinary catheter?
- ABy sliding the catheter in and out a little to clean it
- BWith routine hygiene, using soap and water during daily washing
- CWith antiseptic cream applied to the meatus every shift
- DWith daily bladder irrigation using an antibiotic solution through the catheter
4.Infection control & patient safetyHard
A patient is on contact precautions. Which task is appropriate for the nurse to delegate to assistive personnel?
- AAssessing the wound for new signs of infection during the bath
- BTeaching the family how to follow the precautions
- CHelping the patient bathe while wearing a gown and gloves
- DDeciding when the precautions can be stopped
5.Lab values & electrolytesMedium
A patient with chronic kidney disease has a magnesium of 3.8 mEq/L (1.9 mmol/L). Which product is the most likely cause?
- AExcess alcohol use over many years
- BProton pump inhibitors taken long term
- CLoop diuretics such as furosemide
- DMagnesium-containing laxatives or antacids
6.Lab values & electrolytesHard
The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?
- A"I'll wash my hands before eating and after the toilet"
- B"I'll call the clinic if my temperature rises"
- C"I'll avoid people who have a cold or the flu"
- D"I'll check my temperature rectally to be accurate"
7.Clinical nursingMedium
A rising serum creatinine most often indicates:
- AIncreased muscle strength
- BReduced kidney function
- CDehydration of the skin only
- DImproved liver function
8.Clinical nursingHard
Which set of findings best distinguishes cardiogenic shock from hypovolaemic shock?
- ARaised jugular venous pressure and lung crackles
- BReduced urine output
- CTachycardia, hypotension and a weak, thready peripheral pulse
- DCool, pale skin
9.Med-surg: cardiovascular & respiratoryMedium
Unless fluids are restricted, why are patients with pneumonia encouraged to drink plenty?
- ATo lower the temperature by diluting the blood plasma
- BTo make the cough completely stop
- CTo flush the bacteria out through the urine
- DTo prevent dehydration and keep secretions thinner
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?
- AHigh-concentration oxygen by non-rebreather mask
- BStopping the nebulised bronchodilators
- CNon-invasive ventilation (NIV)
- DIV sedation to slow the breathing rate
11.Med-surg: neuro, endocrine & renalMedium
A patient receives phenytoin through a nasogastric tube along with continuous enteral feed. Which issue should the nurse know about?
- AThe feed increases phenytoin levels and causes toxicity within hours
- BPhenytoin must be crushed and mixed into the feed bag
- CThe feed can reduce phenytoin absorption, so the feed is often paused around the dose
- DPhenytoin makes the feed curdle, so the two must never be used in one patient
12.Med-surg: neuro, endocrine & renalHard
A nurse teaches a patient with Hashimoto's thyroiditis about levothyroxine. Which statement shows a need for further teaching?
- A"I will take the tablets at the same time each day."
- B"I can stop the tablets once I feel back to normal."
- C"I will report palpitations or chest pain."
- D"I will have regular blood tests to check my dose."
13.Med-surg: GI, perioperative & oncologyMedium
Which statement about pain relief in acute pancreatitis is correct?
- AOpioids must never be used in pancreatitis
- BOpioids can be used, and good analgesia is a priority
- CPain relief should be withheld until the diagnosis is certain
- DOnly paracetamol may be given
14.Med-surg: GI, perioperative & oncologyHard
A patient took a large paracetamol (acetaminophen) overdose 6 hours ago and says they feel completely well. Which statement is correct?
- ATreatment is not needed if the patient has not vomited
- BLiver damage may still develop, and appears only days later
- CFeeling well means the dose was too small to cause harm
- DLiver damage after paracetamol occurs only within the first hour or so
3Solutions
1.Prioritization & delegation
Answer: C · “I will breathe in through my mouth and out quickly through my nose.”
Why this is the answer
Pursed-lip breathing means breathing in through the nose and out slowly through pursed lips, making exhalation longer. This keeps airways open and reduces air trapping.
C · “I will breathe in through my mouth and out quickly through my nose.”
2.Prioritization & delegation
Answer: D · The laboratory is calling with a critical potassium result of 2.6 mEq/L
Why this is the answer
A critical potassium of 2.6 mEq/L can cause life-threatening arrhythmias, so it is acted on first: the nurse assesses the patient and informs the provider. The other calls can wait.
D · The laboratory is calling with a critical potassium result of 2.6 mEq/L
3.Infection control & patient safety
Answer: B · With routine hygiene, using soap and water during daily washing
Why this is the answer
Routine perineal hygiene with soap and water is recommended. Antiseptic creams and routine irrigation do not reduce infection, and moving the catheter in and out carries organisms into the bladder.
B · With routine hygiene, using soap and water during daily washing
4.Infection control & patient safety
Answer: C · Helping the patient bathe while wearing a gown and gloves
Why this is the answer
Assistive personnel can carry out routine care for a stable patient, using the correct PPE. Assessment, teaching and clinical judgement, such as deciding when to stop precautions, cannot be delegated to them.
C · Helping the patient bathe while wearing a gown and gloves
5.Lab values & electrolytes
Answer: D · Magnesium-containing laxatives or antacids
Why this is the answer
In kidney failure, magnesium from milk of magnesia, magnesium citrate or magnesium-containing antacids can build up to toxic levels. Patients with CKD are taught to avoid these products. Diuretics, PPIs and alcohol cause low magnesium.Checked against: Magnesium Blood Test · MedlinePlus (NIH) (2023)
D · Magnesium-containing laxatives or antacids
6.Lab values & electrolytes
Answer: D · "I'll check my temperature rectally to be accurate"
Why this is the answer
Rectal temperatures, suppositories and enemas are avoided in neutropenia, because injury to the rectal mucosa can let bacteria into the blood. Prompt reporting of fever, hand hygiene and avoiding sick contacts are correct.
D · "I'll check my temperature rectally to be accurate"
7.Clinical nursing
Answer: B · Reduced kidney function
Why this is the answer
Creatinine is a muscle waste product filtered by the kidneys. A rise shows the glomerular filtration rate is falling, as in acute kidney injury.
B · Reduced kidney function
8.Clinical nursing
Answer: A · Raised jugular venous pressure and lung crackles
Why this is the answer
Both types cause tachycardia, hypotension, cool skin and low urine output. In cardiogenic shock the failing heart causes venous congestion and pulmonary oedema, so large fluid boluses may worsen it.
A · Raised jugular venous pressure and lung crackles
9.Med-surg: cardiovascular & respiratory
Answer: D · To prevent dehydration and keep secretions thinner
Why this is the answer
Fever, sweating and tachypnoea increase insensible fluid loss. Good hydration prevents dehydration and helps keep secretions less sticky. Patients with heart failure or other restrictions need individual plans.
D · To prevent dehydration and keep secretions thinner
10.Med-surg: cardiovascular & respiratory
Answer: C · 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.
C · Non-invasive ventilation (NIV)
11.Med-surg: neuro, endocrine & renal
Answer: C · The feed can reduce phenytoin absorption, so the feed is often paused around the dose
Why this is the answer
Enteral feeds can bind phenytoin and greatly reduce how much is absorbed. Local protocols usually pause the feed before and after the dose and flush the tube. Drug levels are monitored.
C · The feed can reduce phenytoin absorption, so the feed is often paused around the dose
12.Med-surg: neuro, endocrine & renal
Answer: B · "I can stop the tablets once I feel back to normal."
Why this is the answer
In Hashimoto's thyroiditis the gland is permanently damaged, so levothyroxine is usually lifelong. Feeling well shows that the dose is right, not that the disease is cured. Stopping causes symptoms to return.
B · "I can stop the tablets once I feel back to normal."
13.Med-surg: GI, perioperative & oncology
Answer: B · Opioids can be used, and good analgesia is a priority
Why this is the answer
Acute pancreatitis is very painful, and opioids are used as part of multimodal analgesia. There is no good evidence that they worsen the condition. Sedation and breathing are monitored.
B · Opioids can be used, and good analgesia is a priority
14.Med-surg: GI, perioperative & oncology
Answer: B · Liver damage may still develop, and appears only days later
Why this is the answer
Early after paracetamol overdose, patients often have no or few symptoms, but liver injury peaks after about 3–4 days. Treatment with acetylcysteine is guided by timed paracetamol levels and the history.
B · Liver damage may still develop, and appears only days later
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