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
Using the Emergency Severity Index, which level fits a 70-year-old with chest pressure that suggests a heart attack, but normal vital signs?
- ALevel 5
- BLevel 1
- CLevel 4
- DLevel 2
2.Prioritization & delegationHard
A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?
- AAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
- BGive the as-needed sedative so the patient rests comfortably
- CLet the patient sleep, because the saturation is above target
- DIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
3.Infection control & patient safetyMedium
A patient on oxygen is being taken to another department by wheelchair. What should the nurse check first?
- AThat the oxygen is turned off during the transfer to save the supply in the tank
- BThat the portable cylinder has enough oxygen for the whole trip
- CThat the cylinder is the largest size available
- DThat the cylinder is placed on the patient’s lap
4.Infection control & patient safetyHard
A patient with dementia is often found at the exit doors trying to leave the unit. Which measure is most appropriate?
- AGive a sedative each time the patient goes to the door
- BUse an electronic wander alert, supervise closely and offer meaningful activity
- CLock the patient alone in a single room so that they cannot reach the exit doors
- DKeep the patient in a chair with a vest restraint
5.Lab values & electrolytesMedium
A patient takes low-dose methotrexate weekly for rheumatoid arthritis. Which laboratory tests are monitored regularly?
- ATroponin, creatine kinase and myoglobin
- BSerum lithium, sodium and urine specific gravity
- CComplete blood count, liver tests and kidney function
- DSerum amylase, lipase and blood ketones
6.Lab values & electrolytesHard
A patient with a new deep vein thrombosis is on a heparin infusion, and warfarin has just been started. Why is the heparin continued for several days?
- AWarfarin only works when heparin is given at the same time
- BHeparin increases the absorption of warfarin from the gut
- CHeparin prevents the side effects of warfarin
- DWarfarin takes several days to reach its full anticoagulant effect
7.Clinical nursingMedium
Which examination findings suggest a large pleural effusion on one side?
- AA hyper-resonant chest with the trachea pulled towards that side
- BNormal breath sounds and normal percussion
- CDull percussion and reduced breath sounds over the lung base
- DWheeze heard over both lungs
8.Clinical nursingHard
Which ECG change is classically associated with severe hyperkalaemia?
- AProminent U waves
- BA shortened PR interval
- CTall, peaked T waves
- DST depression only
9.Med-surg: cardiovascular & respiratoryMedium
A patient has pneumonia in the right lung only. In which side-lying position will oxygenation usually be best?
- AFlat on the back with no pillows
- BLying on the right side, with the affected lung down
- CProne with the head down
- DLying on the left side, with the healthy lung down
10.Med-surg: cardiovascular & respiratoryHard
A patient on a morphine PCA after surgery is very drowsy, with a respiratory rate of 7/min and pinpoint pupils. SpO₂ is 89%. What should the nurse do first?
- AEncourage the patient to keep pressing the PCA button for comfort
- BGive a sedative to keep the patient comfortable
- CStop the PCA, support breathing, give oxygen and get naloxone
- DLeave the patient to sleep and recheck the observations in an hour
11.Med-surg: neuro, endocrine & renalMedium
Which criterion for acute kidney injury (KDIGO) relates to urine output?
- ABelow 2 mL/kg/h for 1 hour
- BAny change in the colour of the urine
- CBelow 0.5 mL/kg/h for 6 hours or more
- DBelow 1 L in 24 hours whatever the intake
12.Med-surg: neuro, endocrine & renalHard
A patient with Parkinson's disease becomes agitated and confused at night. Which newly prescribed drug should the nurse question?
- AMelatonin
- BHaloperidol
- CParacetamol (acetaminophen)
- DLactulose
13.Med-surg: GI, perioperative & oncologyMedium
Why might urea rise much more than creatinine in a patient with an upper GI bleed?
- ADigested blood is a protein load that raises urea
- BThe bleed always damages the kidney tubules directly
- CCreatinine is lost from the body in the vomit
- DUrea is produced by the bleeding stomach lining
14.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?
- A"I'll chew my food well to avoid blockages."
- B"I'll report if my output becomes very watery and high."
- C"I'll watch for dizziness and dark urine."
- D"I'll drink less so my bag fills more slowly."
3Solutions
1.Prioritization & delegation
Answer: D · Level 2
Why this is the answer
Possible acute coronary syndrome is a high-risk situation, so the patient is ESI level 2 and should be seen very soon. Level 1 is kept for patients who need an immediate life-saving intervention.
2.Prioritization & delegation
Answer: A · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
Why this is the answer
In COPD, drowsiness can be a sign of carbon dioxide retention (hypercapnia), even when the saturation is acceptable. The nurse assesses breathing, escalates and avoids extra oxygen or sedatives that could worsen it.
A · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
3.Infection control & patient safety
Answer: B · That the portable cylinder has enough oxygen for the whole trip
Why this is the answer
The nurse checks the cylinder gauge and makes sure there is enough oxygen for the trip and possible delays. The cylinder is secured in a holder on the chair, not on the patient’s lap.
B · That the portable cylinder has enough oxygen for the whole trip
4.Infection control & patient safety
Answer: B · Use an electronic wander alert, supervise closely and offer meaningful activity
Why this is the answer
Wander alert systems, close supervision, orientation and activity reduce the risk of elopement without restricting the patient. Seclusion, restraints and sedation used for convenience are not appropriate.
B · Use an electronic wander alert, supervise closely and offer meaningful activity
5.Lab values & electrolytes
Answer: C · Complete blood count, liver tests and kidney function
Why this is the answer
Methotrexate can cause bone marrow suppression, liver toxicity and, as it is cleared by the kidneys, toxicity when kidney function falls. The CBC, liver tests and creatinine are checked regularly, and folic acid is usually given to reduce adverse effects.Checked against: Methotrexate · StatPearls (NCBI Bookshelf) (2024)
C · Complete blood count, liver tests and kidney function
6.Lab values & electrolytes
Answer: D · Warfarin takes several days to reach its full anticoagulant effect
Why this is the answer
Warfarin blocks the making of new vitamin K–dependent clotting factors, but existing factors last for days. Heparin is therefore overlapped until the INR has been in the target range, typically for at least 24 hours and after a minimum of about 5 days.
D · Warfarin takes several days to reach its full anticoagulant effect
7.Clinical nursing
Answer: C · Dull percussion and reduced breath sounds over the lung base
Why this is the answer
Fluid in the pleural space muffles breath sounds and makes percussion stony dull. A large effusion may push the trachea away from the affected side.
C · Dull percussion and reduced breath sounds over the lung base
8.Clinical nursing
Answer: C · Tall, peaked T waves
Why this is the answer
Hyperkalaemia causes peaked T waves, then a widened QRS and possibly a sine-wave pattern and arrest. Hypokalaemia causes flat T waves and U waves.
9.Med-surg: cardiovascular & respiratory
Answer: D · Lying on the left side, with the healthy lung down
Why this is the answer
Blood flow goes preferentially to the dependent lung. Placing the healthy lung down matches more blood to the well-ventilated lung, improving oxygenation ("good lung down"). Exceptions include a lung abscess or bleeding, when the affected lung is placed down to protect the healthy one.
D · Lying on the left side, with the healthy lung down
10.Med-surg: cardiovascular & respiratory
Answer: C · Stop the PCA, support breathing, give oxygen and get naloxone
Why this is the answer
Sedation and slow breathing are warning signs of opioid toxicity. The nurse stops the opioid, stimulates the patient, opens the airway, gives oxygen, calls for help and gives naloxone per protocol. Naloxone is short-acting, so the patient is monitored for recurrence.
C · Stop the PCA, support breathing, give oxygen and get naloxone
11.Med-surg: neuro, endocrine & renal
Answer: C · Below 0.5 mL/kg/h for 6 hours or more
Why this is the answer
KDIGO defines AKI as a creatinine rise of ≥26.5 µmol/L (0.3 mg/dL) within 48 hours, a rise to ≥1.5 times baseline within 7 days, or urine output below 0.5 mL/kg/h for 6 hours. Accurate fluid balance charts are therefore essential.
C · Below 0.5 mL/kg/h for 6 hours or more
12.Med-surg: neuro, endocrine & renal
Answer: B · Haloperidol
Why this is the answer
Haloperidol is a dopamine antagonist and can severely worsen parkinsonian symptoms. Metoclopramide is avoided for the same reason. Causes of delirium should be looked for, and specialist advice is needed if a drug is required.
13.Med-surg: GI, perioperative & oncology
Answer: A · Digested blood is a protein load that raises urea
Why this is the answer
Digested blood is a large protein load, so urea rises, often out of proportion to creatinine. Hypovolaemia can also raise urea. A high urea is part of risk scores such as the Glasgow-Blatchford score.
A · Digested blood is a protein load that raises urea
14.Med-surg: GI, perioperative & oncology
Answer: D · "I'll drink less so my bag fills more slowly."
Why this is the answer
Restricting fluids increases dehydration risk with an ileostomy. Patients drink enough, add salt as advised, chew well and report high output or signs of dehydration.
D · "I'll drink less so my bag fills more slowly."
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