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 drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?
- AGive a drink of water
- BRaise the legs above the heart
- CTurn the patient onto their side
- DGive an oral anti-sickness tablet
2.Prioritization & delegationHard
Which assignment by the charge nurse should be changed?
- AAn LPN/LVN is assigned to give oral medications to stable patients
- BAn RN is assigned to a patient receiving a blood transfusion
- CAn LPN/LVN is assigned to admit a new patient from the emergency department
- DA nursing assistant is assigned to help several stable patients with their meals
3.Infection control & patient safetyMedium
Which toy is safest for a toddler?
- AA large toy with no small parts that can come off
- BA bag of marbles to sort by color
- CA toy with small magnets that come out easily
- DA balloon to play with when an adult is out of the room
4.Infection control & patient safetyHard
A patient with pneumonia has low blood pressure and a raised serum lactate. What does the raised lactate suggest?
- ARecovery from the infection is beginning
- BPoor tissue perfusion, a sign of sepsis-related shock
- CMild dehydration from poor intake, with no further concern
- DA normal response to having a fever
5.Lab values & electrolytesMedium
A patient taking warfarin for atrial fibrillation has an INR of 5.2 and no bleeding. What is the nurse’s best action?
- AGive the usual dose and recheck in a month
- BAdvise the patient to stop eating green vegetables from today
- CGive a double dose
- DHold the warfarin dose and inform the prescriber
6.Lab values & electrolytesHard
During an IV magnesium sulfate infusion, which assessment best detects toxicity early?
- ASkin color and capillary refill every hour
- BBlood glucose and pupil size every hour
- CBowel sounds and abdominal girth
- DKnee reflexes, respiratory rate and urine output
7.Clinical nursingMedium
A patient is receiving IV fluids for several days. Which monitoring is essential?
- AFluid balance, regular weights and urea, creatinine and electrolytes
- BPeak flow readings
- CWeekly temperature and a single blood glucose reading
- DMonthly HbA1c
8.Clinical nursingHard
Three days after bowel surgery, a patient has a distended abdomen, vomiting and absent bowel sounds, without colicky pain. What is most likely?
- AParalytic ileus
- BA urinary tract infection
- CAcute cholecystitis
- DNormal recovery after surgery
9.Med-surg: cardiovascular & respiratoryMedium
A woman had lymph nodes removed from her left armpit for breast cancer. Which advice helps reduce the risk of lymphoedema?
- AAvoid BP cuffs and injections on the left arm where possible
- BKeep the left arm hanging down and as still as possible all day
- CUse only the left arm for heavy lifting to build up its muscles
- DApply tight jewellery to the left wrist
10.Med-surg: cardiovascular & respiratoryHard
A woman starting rifampicin (rifampin) for tuberculosis uses a combined oral contraceptive pill. What advice is correct?
- AContinue the pill as usual, because there is no interaction with TB drugs
- BUse another reliable method, as rifampicin reduces the pill's effect
- CStop all contraception during TB treatment, as pregnancy cannot occur
- DTake two pills a day to make up for the drug
11.Med-surg: neuro, endocrine & renalMedium
Which statement about hyperosmolar hyperglycaemic state (HHS) is correct?
- AIt is seen mainly in young children with type 1 diabetes
- BIt always causes high blood ketones and a severe metabolic acidosis
- CIt develops within minutes and is less dangerous than DKA
- DIt mainly affects older people with type 2 diabetes, over days
12.Med-surg: neuro, endocrine & renalHard
A nurse teaches a carer to give buccal midazolam for prolonged seizures. Which statement shows a need for further teaching?
- A"I will call an ambulance if the care plan tells me to."
- B"I will write down the time the seizure started and the time I gave the dose."
- C"I will put something between his teeth so he does not bite his tongue."
- D"I will give it into the space between his gum and cheek."
13.Med-surg: GI, perioperative & oncologyMedium
Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?
- ANew diarrhoea or abdominal pain
- BMild tiredness after a busy day
- CSlight hair thinning over months
- DA small bruise after a knock
14.Med-surg: GI, perioperative & oncologyHard
A category (stage) 4 pressure ulcer is now healing and shallower. How should it be documented according to standard guidance?
- AAs a healing category 4 pressure ulcer
- BAs a fully healed ulcer that can be removed from the record
- CAs a category 2 pressure ulcer now
- DAs a category 1 pressure ulcer now
3Solutions
1.Prioritization & delegation
Answer: C · Turn the patient onto their side
Why this is the answer
A drowsy patient who vomits can aspirate. Turning them to the side lets vomit drain from the mouth; suction and a prescribed antiemetic follow.
C · Turn the patient onto their side
2.Prioritization & delegation
Answer: C · An LPN/LVN is assigned to admit a new patient from the emergency department
Why this is the answer
Admitting a new patient includes the initial assessment and plan of care, which belong to the RN. The other assignments match each staff member’s role.
C · An LPN/LVN is assigned to admit a new patient from the emergency department
3.Infection control & patient safety
Answer: A · A large toy with no small parts that can come off
Why this is the answer
Small parts, marbles, magnets and uninflated or broken balloons are choking hazards for young children. Toys should be large, sturdy and suited to the child’s age.
A · A large toy with no small parts that can come off
4.Infection control & patient safety
Answer: B · Poor tissue perfusion, a sign of sepsis-related shock
Why this is the answer
When tissues are poorly perfused, cells switch to anaerobic metabolism and lactate rises. In a patient with infection and hypotension, this points to septic shock and needs urgent treatment.
B · Poor tissue perfusion, a sign of sepsis-related shock
5.Lab values & electrolytes
Answer: D · Hold the warfarin dose and inform the prescriber
Why this is the answer
An INR of 5.2 is far above the target and increases the bleeding risk. The nurse holds the dose, checks for signs of bleeding and informs the prescriber, who may prescribe a lower dose or vitamin K.Checked against: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024); Warfarin · MedlinePlus (NIH) (2026)
D · Hold the warfarin dose and inform the prescriber
6.Lab values & electrolytes
Answer: D · Knee reflexes, respiratory rate and urine output
Why this is the answer
Loss of the knee reflex is an early warning sign of magnesium toxicity and appears before slowed breathing. Magnesium is cleared by the kidneys, so falling urine output increases the risk. IV calcium gluconate counteracts magnesium toxicity.Checked against: Magnesium Toxicity · StatPearls (NCBI Bookshelf) (2026); Magnesium Toxicity · StatPearls (NCBI Bookshelf)
D · Knee reflexes, respiratory rate and urine output
7.Clinical nursing
Answer: A · Fluid balance, regular weights and urea, creatinine and electrolytes
Why this is the answer
IV fluids can cause overload or electrolyte imbalance. Fluid balance charts, weight, clinical assessment and blood tests guide the prescription.
A · Fluid balance, regular weights and urea, creatinine and electrolytes
8.Clinical nursing
Answer: A · Paralytic ileus
Why this is the answer
Paralytic ileus is a temporary loss of gut movement, common after abdominal surgery. Bowel sounds are absent, unlike mechanical obstruction where they are often high-pitched. Management includes nil by mouth, NG decompression, fluids and correcting electrolytes.
9.Med-surg: cardiovascular & respiratory
Answer: A · Avoid BP cuffs and injections on the left arm where possible
Why this is the answer
After axillary node removal, the arm's lymph drainage is reduced. Patients are advised to protect the skin, treat cuts promptly, avoid tight items and, where possible, avoid BP measurements, cannulation and injections on that arm. Gentle exercise helps lymph flow.
A · Avoid BP cuffs and injections on the left arm where possible
10.Med-surg: cardiovascular & respiratory
Answer: B · Use another reliable method, as rifampicin reduces the pill's effect
Why this is the answer
Rifampicin induces liver enzymes that break down oestrogen and progestogen, so hormonal contraception may fail. A non-hormonal or unaffected method, such as a copper IUD, is advised during and for a time after treatment. The interaction also affects warfarin and many other drugs.
B · Use another reliable method, as rifampicin reduces the pill's effect
11.Med-surg: neuro, endocrine & renal
Answer: D · It mainly affects older people with type 2 diabetes, over days
Why this is the answer
HHS develops over days, often triggered by infection, with extreme hyperglycaemia, very high osmolality and profound dehydration, frequently with confusion. Enough insulin is present to prevent marked ketosis. Mortality is higher than in DKA, and there is a high risk of thrombosis.
D · It mainly affects older people with type 2 diabetes, over days
12.Med-surg: neuro, endocrine & renal
Answer: C · "I will put something between his teeth so he does not bite his tongue."
Why this is the answer
Nothing should ever be put between the teeth during a seizure. Buccal midazolam is given between the gum and cheek, so the mouth does not need to be forced open. Timing the seizure and following the emergency care plan are correct.
C · "I will put something between his teeth so he does not bite his tongue."
13.Med-surg: GI, perioperative & oncology
Answer: A · 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.
A · New diarrhoea or abdominal pain
14.Med-surg: GI, perioperative & oncology
Answer: A · As a healing category 4 pressure ulcer
Why this is the answer
Pressure ulcers are not "reverse staged" because granulation tissue does not replace the muscle, fat and dermis that were lost. The wound is described as a healing category 4 ulcer.
A · As a healing category 4 pressure ulcer
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