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
During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?
- AWait for the next contraction before acting
- BRelieve pressure on the cord by lifting the presenting part with a gloved hand
- CAsk the patient to walk around the room to bring the baby lower and speed up labor
- DPush the cord back into the uterus
2.Prioritization & delegationHard
After report, which patient should the nurse assess first?
- A1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
- BDay 2 after gallbladder surgery: pain 6/10, next analgesic due in 30 minutes
- CType 2 diabetes: glucose 210 mg/dL (11.7 mmol/L) before lunch, no symptoms
- DCOPD on 2 L/min oxygen: SpO₂ 90%, respiratory rate 22/min, at usual baseline
3.Infection control & patient safetyMedium
A child has swallowed a button battery. Why is this urgent?
- AIt always passes through the gut without harm
- BIt can burn through the lining of the esophagus within hours
- CIt is only harmful if several batteries are swallowed
- DThe only risk is poisoning from heavy metals years later
4.Infection control & patient safetyHard
A nurse has a needlestick from a patient with hepatitis B. The nurse finished the vaccine series and has a documented protective antibody level. Which statement is correct?
- AThe nurse must stop all patient care for six months
- BHepatitis B immune globulin and a complete new vaccine series are both needed at once
- CNo hepatitis B treatment is needed, but the injury is still reported and followed up
- DNo reporting is needed because the nurse is immune
5.Lab values & electrolytesMedium
A patient's levothyroxine dose was changed today. When is the TSH usually rechecked?
- AAfter about 1 year
- BAfter about 24 hours
- CAfter about 6–8 weeks
- DAfter about 3 days
6.Lab values & electrolytesHard
A patient taking apixaban asks why they do not need regular INR tests like their neighbor on warfarin. What is the best explanation?
- AApixaban is monitored with an aPTT every day instead
- BThe INR is checked secretly together with the other routine blood tests
- CIts effect is predictable, so routine clotting tests are not needed
- DApixaban does not actually thin the blood
7.Clinical nursingMedium
Which signs suggest a blood transfusion reaction in the first minutes?
- AMild hunger
- BSlow, steady rise in haemoglobin over the next day
- CImproved colour and energy
- DFever, chills, back pain and low blood pressure
8.Clinical nursingHard
A nurse teaches a patient with reflux disease. Which statement shows a need for further teaching?
- A"A big meal just before bed is fine if I take my tablet."
- B"I will try to lose some weight over the next months."
- C"I will cut down on alcohol."
- D"I will raise the head of my bed with blocks."
9.Med-surg: cardiovascular & respiratoryMedium
A patient has a raised B-type natriuretic peptide (BNP or NT-proBNP). What does this mainly reflect?
- ADamage to skeletal muscle after a fall
- BStretch and pressure overload of the ventricles
- CIschaemic damage to the heart muscle
- DInflammation of the liver from congestion
10.Med-surg: cardiovascular & respiratoryHard
A patient with rheumatoid arthritis is due to start an anti-TNF biologic drug. Which screening is essential beforehand?
- AAn exercise ECG test on a treadmill
- BA peak flow diary for a month
- CA sweat chloride test
- DScreening for latent tuberculosis
11.Med-surg: neuro, endocrine & renalMedium
A patient with Addison's disease takes fludrocortisone as well as hydrocortisone. Why?
- ATo lower the blood pressure
- BTo treat a low thyroid hormone level
- CTo replace the missing adrenaline
- DTo replace the missing aldosterone
12.Med-surg: neuro, endocrine & renalHard
During an alteplase infusion for stroke, the patient develops a severe headache, vomiting and a falling GCS. What should the nurse do first?
- AStop the infusion and call the stroke team urgently
- BGive a sedative to settle the patient and continue
- CSpeed up the infusion so that it finishes sooner
- DGive an antiemetic and recheck the GCS in an hour's time
13.Med-surg: GI, perioperative & oncologyMedium
Which complication is more typical of Crohn's disease than of ulcerative colitis?
- AInflammation limited to the rectal lining
- BBleeding only from the rectum
- CDisease that is cured by removing the colon
- DFistulas between the bowel and other organs
14.Med-surg: GI, perioperative & oncologyHard
A patient's platelet count is 18 × 109/L (18,000/µL). Which order should the nurse question?
- AOral paracetamol for headache
- BAn intramuscular injection
- CA soft diet with mouthwashes
- DDaily full blood count
3Solutions
1.Prioritization & delegation
Answer: B · Relieve pressure on the cord by lifting the presenting part with a gloved hand
Why this is the answer
In cord prolapse, the presenting part can compress the cord and cut off fetal oxygen. The nurse lifts the presenting part off the cord, calls for help and positions the patient (for example knee-chest) while urgent birth is arranged.
B · Relieve pressure on the cord by lifting the presenting part with a gloved hand
2.Prioritization & delegation
Answer: A · 1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
Why this is the answer
Back pain, tachycardia and hypotension after a femoral puncture suggest retroperitoneal bleeding, which can be hidden and fatal. The COPD patient is at baseline, the pain is expected and being treated, and the glucose is high but not an emergency.
A · 1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
3.Infection control & patient safety
Answer: B · It can burn through the lining of the esophagus within hours
Why this is the answer
A button battery lodged in the esophagus can cause severe chemical burns within a few hours, so the child needs emergency assessment and often removal. It should never be treated as harmless.
B · It can burn through the lining of the esophagus within hours
4.Infection control & patient safety
Answer: C · No hepatitis B treatment is needed, but the injury is still reported and followed up
Why this is the answer
A documented vaccine responder is protected against hepatitis B and needs no hepatitis B prophylaxis. The exposure is still reported, because the nurse and source patient need assessment for HIV and hepatitis C as well.
C · No hepatitis B treatment is needed, but the injury is still reported and followed up
5.Lab values & electrolytes
Answer: C · After about 6–8 weeks
Why this is the answer
Levothyroxine has a half-life of about a week, so a steady state takes about 6 weeks. The TSH is therefore rechecked about 6–8 weeks after a dose change; checking earlier gives a misleading result.Checked against: Hypothyroidism · MedlinePlus (NIH) (2024)
C · After about 6–8 weeks
6.Lab values & electrolytes
Answer: C · Its effect is predictable, so routine clotting tests are not needed
Why this is the answer
Direct oral anticoagulants such as apixaban have predictable effects at fixed doses, so routine INR testing is not needed. Kidney and liver function, adherence and signs of bleeding are monitored, and the INR does not reliably measure their effect.
C · Its effect is predictable, so routine clotting tests are not needed
7.Clinical nursing
Answer: D · Fever, chills, back pain and low blood pressure
Why this is the answer
An acute haemolytic or febrile reaction can cause fever, rigors, loin or back pain, breathlessness and hypotension. Stop the transfusion and call for help.
D · Fever, chills, back pain and low blood pressure
8.Clinical nursing
Answer: A · "A big meal just before bed is fine if I take my tablet."
Why this is the answer
Large late meals increase reflux even when a PPI is taken. Raising the head of the bed, losing weight and reducing alcohol are correct measures.
A · "A big meal just before bed is fine if I take my tablet."
9.Med-surg: cardiovascular & respiratory
Answer: B · Stretch and pressure overload of the ventricles
Why this is the answer
Natriuretic peptides are released by ventricular myocytes in response to wall stretch. A normal level makes heart failure unlikely; a raised level supports the diagnosis and reflects severity. Levels can also be raised in renal failure and older age. Troponin, not BNP, reflects myocardial necrosis.
B · Stretch and pressure overload of the ventricles
10.Med-surg: cardiovascular & respiratory
Answer: D · Screening for latent tuberculosis
Why this is the answer
TNF-alpha is essential for containing TB in granulomas. Anti-TNF drugs can reactivate latent TB, sometimes as severe disseminated disease. Patients are screened (history, chest X-ray, IGRA) and treated for latent TB before starting.
D · Screening for latent tuberculosis
11.Med-surg: neuro, endocrine & renal
Answer: D · To replace the missing aldosterone
Why this is the answer
In primary adrenal insufficiency, both cortisol and aldosterone are lacking. Hydrocortisone replaces cortisol, and fludrocortisone replaces aldosterone to keep sodium, potassium and blood pressure normal.
D · To replace the missing aldosterone
12.Med-surg: neuro, endocrine & renal
Answer: A · Stop the infusion and call the stroke team urgently
Why this is the answer
New headache, vomiting, hypertension or neurological deterioration during or after thrombolysis may indicate symptomatic intracranial haemorrhage. The infusion is stopped, urgent medical review arranged and an urgent CT scan and coagulation tests anticipated.
A · Stop the infusion and call the stroke team urgently
13.Med-surg: GI, perioperative & oncology
Answer: D · Fistulas between the bowel and other organs
Why this is the answer
Transmural inflammation in Crohn's disease can create fistulas, abscesses and strictures. Ulcerative colitis is mucosal, and removing the colon and rectum is curative.
D · Fistulas between the bowel and other organs
14.Med-surg: GI, perioperative & oncology
Answer: B · An intramuscular injection
Why this is the answer
IM injections can cause haematomas in severe thrombocytopenia. Rectal procedures, NSAIDs and aspirin are also avoided. The nurse checks with the prescriber and the oral or IV route is used where possible.
B · An intramuscular injection
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