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 has a serum potassium of 2.9 mEq/L. Which finding should the nurse expect?
- AA rise in urine output and thirst only
- BTall, peaked T waves and muscle twitching
- CFlushed, warm skin and a slow heart rate
- DMuscle weakness and U waves on the ECG
2.Prioritization & delegationHard
A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?
- ADecline, explain why and suggest who can safely do it
- BDo it just this once and promise the provider not to do it again
- CAsk a nursing assistant to do it instead
- DDo it, because the provider gave the instruction
3.Infection control & patient safetyMedium
A patient walking with a gait belt suddenly starts to fall. What should the nurse do?
- ALet go of the belt and run to call for help
- BPull the patient backwards quickly toward the bed
- CGrab the patient under both arms and try hard to keep them standing up
- DHold the belt, widen the stance and ease the patient gently to the floor
4.Infection control & patient safetyHard
A nurse calculates a child’s prescribed dose and finds it is ten times higher than the usual dose for the child’s weight. What should the nurse do?
- AHold the dose and verify it with the prescriber and pharmacist
- BGive half the dose and watch the child closely
- CGive it, because the prescriber must have a reason
- DGive one-tenth of the dose without telling anyone about it
5.Lab values & electrolytesMedium
A patient taking a statin reports new, unexplained muscle pain and weakness. Which laboratory test would the nurse expect to be ordered?
- ACardiac troponin
- BCreatine kinase (CK)
- CSerum lipase
- DSerum ammonia
6.Lab values & electrolytesHard
A patient with suspected Cushing syndrome takes dexamethasone at night. The next morning, the cortisol is still high. What does this suggest?
- ACortisol is being produced without normal feedback control
- BThe result is normal, as dexamethasone raises cortisol
- CThe adrenal glands are not able to produce enough cortisol
- DThe patient has primary hypothyroidism instead
7.Clinical nursingMedium
Which drug is first-line in an acute asthma attack?
- AA long-acting inhaled corticosteroid, used alone at a higher dose
- BA nebulised or inhaled short-acting beta2-agonist (salbutamol/albuterol)
- CAn oral antihistamine such as cetirizine taken every few hours
- DAn oral beta-blocker
8.Clinical nursingHard
Four call bells ring at the same time. Which patient should the nurse see first?
- AA patient asking what time they will be discharged
- BA patient who needs help to go to the toilet and has rung twice
- CA patient who has just become breathless after starting an IV antibiotic
- DA patient asking for pain relief for chronic back pain that they rate as 3/10
9.Med-surg: cardiovascular & respiratoryMedium
How does varenicline help people stop smoking?
- AIt partly stimulates and partly blocks nicotine receptors
- BIt speeds the clearance of nicotine by the liver
- CIt replaces nicotine through the skin, like a nicotine patch
- DIt makes cigarettes taste of metal so smoking feels unpleasant
10.Med-surg: cardiovascular & respiratoryHard
A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?
- AA catheter-related deep vein thrombosis
- BA local skin allergy to the dressing
- CLymphoedema from lying in bed
- DAn expected effect of the antibiotic
11.Med-surg: neuro, endocrine & renalMedium
Which blood gas pattern is typical of acute kidney injury?
- AHigh pH and high bicarbonate
- BLow pH and low bicarbonate
- CLow pH and high carbon dioxide only
- DHigh pH and low carbon dioxide
12.Med-surg: neuro, endocrine & renalHard
A patient with myasthenia gravis is admitted with pneumonia. Which newly prescribed antibiotic should the nurse question?
- AAmoxicillin
- BGentamicin
- CBenzylpenicillin
- DCeftriaxone
13.Med-surg: GI, perioperative & oncologyMedium
How is the height of an epidural sensory block usually checked?
- AMeasuring the patient's blood glucose level
- BChecking the colour of the patient's urine
- CTapping the knee with a reflex hammer and recording the score
- DTesting sensation to cold with ice or a cold spray
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?
- ADouble both doses, because bleeding means the stent is at greater risk of clotting
- BReport the bleed; the team decides with cardiology input, balancing bleeding against stent thrombosis
- CStop both drugs permanently, because any bleeding means they are no longer safe
- DContinue both drugs unchanged and do not mention the bleeding to the team
3Solutions
1.Prioritization & delegation
Answer: D · Muscle weakness and U waves on the ECG
Why this is the answer
Hypokalemia causes muscle weakness, cramps and arrhythmias, with flattened T waves and U waves on the ECG. Peaked T waves are a sign of hyperkalemia.
D · Muscle weakness and U waves on the ECG
2.Prioritization & delegation
Answer: A · Decline, explain why and suggest who can safely do it
Why this is the answer
Nurses must work within their legal scope of practice, even when asked by a provider. The nurse declines, explains the reason and helps find a suitable professional.
A · Decline, explain why and suggest who can safely do it
3.Infection control & patient safety
Answer: D · Hold the belt, widen the stance and ease the patient gently to the floor
Why this is the answer
The nurse keeps hold of the gait belt, takes a wide base of support and slides the patient down along their own leg to the floor, protecting the head. This controls the fall and protects the nurse’s back.
D · Hold the belt, widen the stance and ease the patient gently to the floor
4.Infection control & patient safety
Answer: A · Hold the dose and verify it with the prescriber and pharmacist
Why this is the answer
Tenfold errors are common in pediatrics, usually from decimal or unit mistakes. The nurse holds the dose and clarifies it, and never changes the dose on their own.
A · Hold the dose and verify it with the prescriber and pharmacist
5.Lab values & electrolytes
Answer: B · Creatine kinase (CK)
Why this is the answer
Statins can cause myopathy and, rarely, rhabdomyolysis. A raised CK confirms muscle injury, and the provider may stop the statin. The nurse also asks about dark urine, which can signal myoglobin in the urine.Checked against: Creatine Kinase · MedlinePlus (NIH) (2023)
6.Lab values & electrolytes
Answer: A · Cortisol is being produced without normal feedback control
Why this is the answer
Dexamethasone normally suppresses ACTH and lowers morning cortisol. Failure to suppress suggests autonomous cortisol excess (Cushing syndrome). Further tests then find the source, such as a pituitary or adrenal tumor.
A · Cortisol is being produced without normal feedback control
7.Clinical nursing
Answer: B · A nebulised or inhaled short-acting beta2-agonist (salbutamol/albuterol)
Why this is the answer
Short-acting beta2-agonists relieve bronchospasm within minutes. Oxygen to target, steroids and other treatments are added according to severity.
B · A nebulised or inhaled short-acting beta2-agonist (salbutamol/albuterol)
8.Clinical nursing
Answer: C · A patient who has just become breathless after starting an IV antibiotic
Why this is the answer
Breathlessness soon after a new IV antibiotic suggests possible anaphylaxis, an airway and breathing emergency. The infusion should be stopped and the patient assessed immediately.
C · A patient who has just become breathless after starting an IV antibiotic
9.Med-surg: cardiovascular & respiratory
Answer: A · It partly stimulates and partly blocks nicotine receptors
Why this is the answer
Varenicline is a partial agonist at nicotinic acetylcholine receptors. It reduces cravings and withdrawal and makes smoking less rewarding. Nausea is common, and patients are asked to report mood changes.
A · It partly stimulates and partly blocks nicotine receptors
10.Med-surg: cardiovascular & respiratory
Answer: A · A catheter-related deep vein thrombosis
Why this is the answer
Upper-limb DVT is a recognised complication of PICCs and other central lines. Arm swelling, pain and distended veins should be reported, and an ultrasound arranged. The line is not flushed forcefully, and treatment usually involves anticoagulation.
A · A catheter-related deep vein thrombosis
11.Med-surg: neuro, endocrine & renal
Answer: B · Low pH and low bicarbonate
Why this is the answer
Failing kidneys cannot excrete acid or regenerate bicarbonate, causing a metabolic acidosis with low pH and low bicarbonate. The patient may breathe faster to blow off CO2 as compensation.
B · Low pH and low bicarbonate
12.Med-surg: neuro, endocrine & renal
Answer: B · Gentamicin
Why this is the answer
Aminoglycosides such as gentamicin can impair neuromuscular transmission and trigger a myasthenic crisis. Fluoroquinolones, magnesium and some other drugs carry similar warnings. The nurse checks with the prescriber before giving it.
13.Med-surg: GI, perioperative & oncology
Answer: D · Testing sensation to cold with ice or a cold spray
Why this is the answer
The level at which the patient no longer feels cold shows the upper extent of the sensory block. Motor block is assessed with a scale such as Bromage. A rising block or new weakness is reported.
D · Testing sensation to cold with ice or a cold spray
14.Med-surg: GI, perioperative & oncology
Answer: B · 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.
B · Report the bleed; the team decides with cardiology input, balancing bleeding against stent thrombosis
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