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
Which medication order should the nurse question?
- APotassium chloride by IV push
- BPotassium chloride oral solution diluted in juice
- COral potassium chloride with food
- DPotassium chloride diluted in an IV bag via a pump
2.Prioritization & delegationHard
Which patient should the nurse escalate to the rapid response team first?
- AA patient with cellulitis whose temperature is 38.1 °C, with otherwise normal vital signs
- BA patient after knee surgery with pain of 6/10 and normal vital signs
- CA patient with known hypertension whose blood pressure is 152/94 mmHg and who feels well
- DA patient with a urinary infection who is newly confused, with a respiratory rate of 26/min and a systolic blood pressure of 94 mmHg
3.Infection control & patient safetyMedium
Before giving a tablet, the patient says, “This pill looks different from my usual one.” What should the nurse do?
- AGive half the pill and watch for any unusual effects
- BStop and recheck the order and the drug before giving it
- CTell the patient that all pills look different in hospital
- DReassure the patient and give the pill
4.Infection control & patient safetyHard
A patient on chemotherapy develops shingles over several areas on both sides of the body. Which precautions are needed?
- AAirborne and contact precautions until all lesions are crusted
- BContact precautions only, with gloves for dressing changes
- CDroplet precautions until the pain settles
- DStandard precautions only, with the lesions covered
5.Lab values & electrolytesMedium
When should a blood sample for a digoxin level be drawn to be interpreted correctly?
- AAt any time, because digoxin levels do not change during the day
- BOnly after a meal, because food is needed for absorption
- CAt least 6–8 hours after a dose, often just before the next one
- DWithin 30 minutes after an oral dose to show the peak level
6.Lab values & electrolytesHard
A patient with a large, fast-growing lymphoma will start chemotherapy tomorrow. Which plan best prevents tumor lysis syndrome?
- AIV hydration, a uric acid-lowering drug and frequent electrolytes
- BFluid restriction and a high-potassium diet before the treatment
- CCalcium supplements and a high-phosphate diet during treatment
- DNo special measures, because the risk starts only after a week
7.Clinical nursingMedium
A patient's NEWS2 score has risen to 7. What is the appropriate response?
- AEmergency assessment by a clinical team with critical care skills
- BContinue observations every 12 hours
- CRecord the score, increase observations and wait for the morning ward round
- DGive a sedative and recheck later
8.Clinical nursingHard
Why should chronic hypernatraemia be corrected gradually?
- AFast correction causes osmotic demyelination from swelling of the kidneys
- BSlow correction is only needed in children
- CFast correction causes severe hyperkalaemia
- DLowering the sodium too fast can cause cerebral oedema
9.Med-surg: cardiovascular & respiratoryMedium
After an above-knee amputation, which measure helps prevent a hip flexion contracture?
- ASitting in a chair for most of the day with the hips bent
- BKeeping a pillow under the stump at all times, day and night
- CLying prone for periods and avoiding pillows under the stump
- DKeeping the hip bent to reduce stump swelling
10.Med-surg: cardiovascular & respiratoryHard
A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?
- AIt is needed only while she has palpitations
- BHer risk of stroke is high, and an anticoagulant lowers it
- CIt is given to lower her blood pressure
- DThe anticoagulant will stop the irregular heartbeat for good
11.Med-surg: neuro, endocrine & renalMedium
Which urine finding best distinguishes diabetes insipidus from SIADH?
- ADI gives dilute urine; SIADH gives concentrated urine
- BDI gives glucose in the urine; SIADH gives protein
- CDI gives concentrated urine; SIADH gives dilute urine
- DBoth conditions give very concentrated urine
12.Med-surg: neuro, endocrine & renalHard
A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?
- AThe kidney will start to produce far too much urine
- BThe tablets will make the vomiting stop
- CThe patient may not be absorbing their immunosuppressants
- DVomiting proves that rejection has already happened
13.Med-surg: GI, perioperative & oncologyMedium
What is TENS?
- AA device that sends mild electrical pulses through skin pads
- BA type of epidural catheter inserted in theatre
- CA strong opioid given through the skin as a weekly adhesive patch
- DA pain score used for babies
14.Med-surg: GI, perioperative & oncologyHard
A patient with a leg ulcer has an ABPI of 0.5. The doctor's plan mentions starting strong compression bandages. What should the nurse do?
- AApply compression but only at night
- BApply compression and elevate the leg above the heart all day
- CApply the strongest compression to speed healing
- DWithhold strong compression and discuss urgent vascular referral
3Solutions
1.Prioritization & delegation
Answer: A · Potassium chloride by IV push
Why this is the answer
Potassium chloride must never be given by IV push, because a rapid dose can cause cardiac arrest. It is diluted and given slowly through an infusion pump.
A · Potassium chloride by IV push
2.Prioritization & delegation
Answer: D · A patient with a urinary infection who is newly confused, with a respiratory rate of 26/min and a systolic blood pressure of 94 mmHg
Why this is the answer
New confusion, a respiratory rate of 22/min or more and a systolic blood pressure of 100 mmHg or less (the qSOFA criteria) in a patient with an infection point to possible sepsis with a high risk of deterioration. The patient needs urgent escalation, cultures and early antibiotics. Early warning scores such as NEWS2 give the same signal. The other patients are stable.
D · A patient with a urinary infection who is newly confused, with a respiratory rate of 26/min and a systolic blood pressure of 94 mmHg
3.Infection control & patient safety
Answer: B · Stop and recheck the order and the drug before giving it
Why this is the answer
A patient’s concern is a safety check. The nurse stops and checks the order, the drug, the dose and the patient, and contacts the pharmacy if needed. Sometimes the reason is a different brand, but this must be confirmed first.
B · Stop and recheck the order and the drug before giving it
4.Infection control & patient safety
Answer: A · Airborne and contact precautions until all lesions are crusted
Why this is the answer
Lesions over several areas on both sides mean disseminated zoster, which can spread through the air like chickenpox. Airborne and contact precautions are used until all lesions are dry and crusted. Localized zoster in an immunocompromised patient also needs airborne and contact precautions, but only until dissemination is ruled out.
A · Airborne and contact precautions until all lesions are crusted
5.Lab values & electrolytes
Answer: C · At least 6–8 hours after a dose, often just before the next one
Why this is the answer
Digoxin distributes slowly from blood to tissues, so a sample taken too soon after a dose is falsely high. Levels are drawn at least 6–8 hours after a dose, commonly as a trough before the next dose.
C · At least 6–8 hours after a dose, often just before the next one
6.Lab values & electrolytes
Answer: A · IV hydration, a uric acid-lowering drug and frequent electrolytes
Why this is the answer
Prevention includes aggressive IV hydration, drugs such as allopurinol or rasburicase to lower uric acid, and frequent monitoring of potassium, phosphate, calcium, uric acid and creatinine. Tumor lysis usually begins within 1–3 days of starting treatment.Checked against: Uric Acid Test · MedlinePlus (NIH) (2026)
A · IV hydration, a uric acid-lowering drug and frequent electrolytes
7.Clinical nursing
Answer: A · Emergency assessment by a clinical team with critical care skills
Why this is the answer
In NEWS2, a score of 7 or more triggers an emergency response, usually continuous monitoring and urgent review by a team competent in managing critically ill patients.
A · Emergency assessment by a clinical team with critical care skills
8.Clinical nursing
Answer: D · Lowering the sodium too fast can cause cerebral oedema
Why this is the answer
In chronic hypernatraemia, brain cells adapt by holding extra solutes. If sodium falls too quickly, water moves into brain cells and causes cerebral oedema, so correction is controlled.
D · Lowering the sodium too fast can cause cerebral oedema
9.Med-surg: cardiovascular & respiratory
Answer: C · Lying prone for periods and avoiding pillows under the stump
Why this is the answer
Prolonged hip flexion, such as long periods sitting or a pillow under the stump, can lead to a fixed contracture that makes fitting a prosthesis difficult. Lying prone for periods, keeping the hip extended and early physiotherapy help prevent it.
C · Lying prone for periods and avoiding pillows under the stump
10.Med-surg: cardiovascular & respiratory
Answer: B · Her risk of stroke is high, and an anticoagulant lowers it
Why this is the answer
In AF, blood stasis in the left atrium causes clots that can travel to the brain. Scores such as CHA₂DS₂-VASc (age, hypertension, diabetes, female sex and others) estimate stroke risk; her score is high. Anticoagulation reduces stroke risk but does not change the rhythm.
B · Her risk of stroke is high, and an anticoagulant lowers it
11.Med-surg: neuro, endocrine & renal
Answer: A · DI gives dilute urine; SIADH gives concentrated urine
Why this is the answer
In DI, lack of ADH effect causes large volumes of dilute urine (specific gravity often below 1.005) with high serum sodium. In SIADH, excess ADH causes low urine output with concentrated urine and low serum sodium.
A · DI gives dilute urine; SIADH gives concentrated urine
12.Med-surg: neuro, endocrine & renal
Answer: C · The patient may not be absorbing their immunosuppressants
Why this is the answer
Vomiting and diarrhoea can reduce absorption of immunosuppressants, raising the risk of rejection, and dehydration can harm the graft. Tacrolimus levels can also rise with diarrhoea. The team may check levels and kidney function.
C · The patient may not be absorbing their immunosuppressants
13.Med-surg: GI, perioperative & oncology
Answer: A · A device that sends mild electrical pulses through skin pads
Why this is the answer
TENS is thought to reduce pain partly through the gate-control mechanism. It is non-invasive and patient-controlled, but is avoided over certain areas and with some implanted devices.
A · A device that sends mild electrical pulses through skin pads
14.Med-surg: GI, perioperative & oncology
Answer: D · Withhold strong compression and discuss urgent vascular referral
Why this is the answer
An ABPI of 0.5 suggests severe arterial disease, and strong compression could cause limb ischaemia. The nurse raises the concern and the patient is referred to vascular specialists.
D · Withhold strong compression and discuss urgent vascular referral
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