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
An anxious patient is breathing very fast and has tingling fingers. The blood gas shows pH 7.51 and PaCO₂ 29 mmHg (3.9 kPa). What should the nurse do first?
- AEncourage the patient to breathe even faster
- BGive oxygen at the highest flow and leave the room
- CGive IV sodium bicarbonate as soon as it can be found
- DStay with the patient and coach slow, calm breathing
2.Prioritization & delegationHard
During a power cut, which patient is the nurse’s first priority?
- AA patient who depends on a ventilator
- BA patient whose bed will not raise electrically
- CA patient watching television when it switched off
- DA patient whose call light is not working
3.Infection control & patient safetyMedium
A new antibiotic is prescribed for a patient. What should the nurse check before giving the first dose?
- AThe patient’s allergies, by checking the record and asking the patient
- BOnly the patient’s blood pressure and pulse before giving the drug
- COnly the time of the patient’s last meal and drink
- DThe patient’s preferred pharmacy
4.Infection control & patient safetyHard
A confused patient keeps pulling at a nasogastric tube. Which approach should be tried first?
- ALess restrictive measures, such as reorientation and a sitter
- BRemoving the tube without consulting the team
- CWrist restraints straight away to protect the tube
- DA sedative so that the patient sleeps quietly through the night
5.Lab values & electrolytesMedium
A patient with hyperkalemia is prescribed an oral potassium binder such as patiromer or sodium zirconium cyclosilicate. How does this drug lower potassium?
- AIt protects the heart muscle against high potassium levels
- BIt moves potassium into cells in the next few minutes
- CIt binds potassium in the gut so it leaves in the stool
- DIt stops the kidneys from absorbing water in the tubules
6.Lab values & electrolytesHard
A patient with cirrhosis and ascites has fever and abdominal tenderness. The ascitic fluid neutrophil count is 400 cells/mm³. What does this indicate?
- ASpontaneous bacterial peritonitis
- BNormal ascitic fluid in cirrhosis
- CBleeding into the abdominal cavity
- DMalignant ascites from cancer
7.Clinical nursingMedium
A blood transfusion is about to start. What is the most important safety check?
- AChecking the patient's dietary preferences
- BWarming all blood in a microwave
- CChecking the patient's weight only
- DPositive patient identification matched to the blood component at the bedside
8.Clinical nursingHard
Why should potassium chloride concentrate never be given as a rapid intravenous injection?
- AIt can cause fatal cardiac arrhythmias
- BIt has no effect when given fast
- CIt causes immediate kidney failure
- DIt crystallises in the vein and blocks the cannula
9.Med-surg: cardiovascular & respiratoryMedium
Rheumatic heart disease most often follows which infection?
- AA fungal infection of the lungs
- BStaphylococcal infection of the skin
- CA viral infection of the upper airway
- DA group A streptococcal throat infection
10.Med-surg: cardiovascular & respiratoryHard
Two days after coronary artery bypass surgery, a patient feels palpitations. The pulse is irregularly irregular at 140/min and BP is 112/70 mmHg. Which rhythm is most likely?
- AAtrial fibrillation
- BSinus tachycardia
- CComplete heart block
- DVentricular fibrillation
11.Med-surg: neuro, endocrine & renalMedium
Why is once-daily prednisolone usually taken in the morning with food?
- ATo match the natural cortisol rhythm and protect the stomach
- BBecause it causes drowsiness and is safer to take during the day
- CBecause food doubles the strength of the dose
- DBecause it cannot be absorbed at night
12.Med-surg: neuro, endocrine & renalHard
A man who takes tamsulosin for BPH is listed for cataract surgery. Which statement is correct?
- AThe dose should be doubled before surgery to prevent urinary retention
- BTamsulosin has no effects outside the urinary tract, so nothing changes
- CThe eye surgeon must be told, as it can cause floppy iris during surgery
- DIt should be swapped for oxybutynin the night before to protect the eye
13.Med-surg: GI, perioperative & oncologyMedium
How should a patient with facial burns usually be positioned?
- AIn any position that keeps the face covered
- BWith the head of the bed raised to reduce swelling
- CLying flat with the head lower than the feet
- DLying face down on the pillow to protect the airway
14.Med-surg: GI, perioperative & oncologyHard
A patient who had a coronary stent placed two months ago, on aspirin and clopidogrel, presents with melaena and is now stable. What is the most appropriate approach to the antiplatelet drugs?
- AStop both drugs permanently, because any bleeding means they are no longer safe
- BDouble both doses, because bleeding means the stent is at greater risk of clotting
- CReport the bleed; the team decides with cardiology input, balancing bleeding against stent thrombosis
- DContinue both drugs unchanged and do not mention the bleeding to the team
3Solutions
1.Prioritization & delegation
Answer: D · Stay with the patient and coach slow, calm breathing
Why this is the answer
These results show respiratory alkalosis caused by hyperventilation. Calming the patient and coaching slower breathing lets carbon dioxide return to normal; the nurse also looks for physical causes.
D · Stay with the patient and coach slow, calm breathing
2.Prioritization & delegation
Answer: A · A patient who depends on a ventilator
Why this is the answer
A ventilator-dependent patient is at immediate risk. The nurse checks that the ventilator is on emergency power or battery and keeps a manual resuscitation bag ready.
A · A patient who depends on a ventilator
3.Infection control & patient safety
Answer: A · The patient’s allergies, by checking the record and asking the patient
Why this is the answer
Before any new drug, the nurse checks recorded allergies and asks the patient directly about past reactions. The patient is then watched closely after the first dose.
A · The patient’s allergies, by checking the record and asking the patient
4.Infection control & patient safety
Answer: A · Less restrictive measures, such as reorientation and a sitter
Why this is the answer
Less restrictive measures are tried first: reorientation, checking for causes such as pain, securing the tube out of sight and having someone stay with the patient. Restraints or sedatives are used only if these fail and the patient is at risk, with an order.
A · Less restrictive measures, such as reorientation and a sitter
5.Lab values & electrolytes
Answer: C · It binds potassium in the gut so it leaves in the stool
Why this is the answer
Potassium binders exchange potassium in the gut for another ion, so potassium is removed from the body in the stool. They act over hours, so they are not used alone for emergencies; calcium protects the heart, and insulin with glucose shifts potassium into cells quickly.Checked against: High potassium level · MedlinePlus (NIH) (2025)
C · It binds potassium in the gut so it leaves in the stool
6.Lab values & electrolytes
Answer: A · Spontaneous bacterial peritonitis
Why this is the answer
An ascitic neutrophil count of 250 cells/mm³ or more indicates spontaneous bacterial peritonitis, which is treated with antibiotics. It can occur without classic signs, so new confusion or worsening kidney function in cirrhosis should also prompt a diagnostic paracentesis.Checked against: Ascites · MedlinePlus (NIH) (2024); Peritonitis · MedlinePlus (NIH) (2026)
A · Spontaneous bacterial peritonitis
7.Clinical nursing
Answer: D · Positive patient identification matched to the blood component at the bedside
Why this is the answer
The patient's identity on the wristband is checked against the compatibility label and prescription at the bedside. Baseline observations are taken before starting.
D · Positive patient identification matched to the blood component at the bedside
8.Clinical nursing
Answer: A · It can cause fatal cardiac arrhythmias
Why this is the answer
A bolus of concentrated potassium can stop the heart. Potassium is always given diluted, at a controlled rate, usually by infusion pump.
A · It can cause fatal cardiac arrhythmias
9.Med-surg: cardiovascular & respiratory
Answer: D · A group A streptococcal throat infection
Why this is the answer
Rheumatic fever is an autoimmune reaction weeks after group A streptococcal pharyngitis. It can permanently damage heart valves, most often the mitral valve. Prompt antibiotic treatment of strep throat prevents it.
D · A group A streptococcal throat infection
10.Med-surg: cardiovascular & respiratory
Answer: A · Atrial fibrillation
Why this is the answer
New atrial fibrillation affects a large proportion of patients in the first days after cardiac surgery, often due to inflammation, electrolyte shifts and stress. Management includes a 12-lead ECG, checking potassium and magnesium, rate or rhythm control and considering anticoagulation.
11.Med-surg: neuro, endocrine & renal
Answer: A · To match the natural cortisol rhythm and protect the stomach
Why this is the answer
Morning dosing mimics the normal early-morning cortisol peak, causes less adrenal suppression and less sleep disturbance. Taking it with food reduces gastric irritation.
A · To match the natural cortisol rhythm and protect the stomach
12.Med-surg: neuro, endocrine & renal
Answer: C · The eye surgeon must be told, as it can cause floppy iris during surgery
Why this is the answer
Tamsulosin blocks alpha-1A receptors in the iris dilator muscle as well as in the prostate, which can cause intraoperative floppy iris syndrome during cataract surgery. The effect can persist after the drug is stopped, so the surgeon must know in advance to plan the operation. Whether to pause it is a decision for the team.
C · The eye surgeon must be told, as it can cause floppy iris during surgery
13.Med-surg: GI, perioperative & oncology
Answer: B · With the head of the bed raised to reduce swelling
Why this is the answer
Raising the head reduces facial and airway swelling. The airway is monitored closely because swelling can increase over the first 24–48 hours.
B · With the head of the bed raised to reduce swelling
14.Med-surg: GI, perioperative & oncology
Answer: C · Report the bleed; the team decides with cardiology input, balancing bleeding against stent thrombosis
Why this is the answer
Early after coronary stenting, stopping dual antiplatelet therapy carries a high risk of stent thrombosis and MI, while continuing increases bleeding. Decisions are made by the medical team, ideally with cardiology and gastroenterology input; often aspirin is continued and the second agent paused briefly or continued depending on bleeding severity and endoscopic findings.
C · Report the bleed; the team decides with cardiology input, balancing bleeding against stent thrombosis
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