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
Which medication order should the nurse question?
- APotassium chloride diluted in an IV bag via a pump
- BPotassium chloride oral solution diluted in juice
- CPotassium chloride by IV push
- DOral potassium chloride with food
2.Prioritization & delegationHard
A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?
- A“I will check with the pharmacist before cold remedies.”
- B“A sudden severe headache is a warning sign.”
- C“I can still eat aged cheese and cured salami.”
- D“I will avoid tap beer and red wine.”
3.Infection control & patient safetyMedium
The laboratory calls with a critical lab result by phone. What should the nurse do?
- AWrite it down, read it back to confirm and report it to the provider promptly
- BRemember the value and enter it in the chart at the end of the shift
- CTell the patient the result first and then call the provider
- DWait for the printed report to arrive before telling the provider about it
4.Infection control & patient safetyHard
Which position is especially dangerous for a patient in physical restraints?
- ASitting upright in bed
- BLying face down (prone)
- CLying on the side
- DLying on the back with the head raised
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’s total calcium is 7.9 mg/dL (2.0 mmol/L), with an albumin of 2.4 g/dL (24 g/L) and no symptoms. Which test would best clarify whether true hypocalcemia is present?
- AA serum sodium
- BA urine specific gravity
- CAn HbA1c
- DAn ionized calcium
7.Clinical nursingMedium
When giving insulin, which statement is correct?
- AAlways inject into the same spot for consistent absorption
- BRapid-acting insulin is given only at bedtime
- CRotate injection sites to avoid lipohypertrophy
- DInsulin should be shaken hard before use
8.Clinical nursingHard
A patient with a COPD exacerbation remains acidotic with a high PaCO2 despite optimal medical treatment and controlled oxygen. Which treatment is usually considered next?
- AStopping all oxygen therapy
- BNon-invasive ventilation
- CSedation to slow the breathing
- D15 L/min oxygen via a non-rebreathe mask
9.Med-surg: cardiovascular & respiratoryMedium
How should a patient breathe in when using a pressurised metered-dose inhaler without a spacer?
- AIn short gasps through the nose while pressing the canister
- BAs hard and fast as possible, then press the canister afterwards
- CNormally, while breathing out through the mouthpiece
- DSlowly and deeply while pressing the canister, then hold the breath
10.Med-surg: cardiovascular & respiratoryHard
A ventilated patient is coughing, and the high-pressure alarm sounds. Coarse sounds are heard over the trachea. What should the nurse do first?
- ADeflate the endotracheal tube cuff fully
- BTurn the alarm off and reassess the patient in an hour
- CIncrease the tidal volume on the ventilator to overcome it
- DAssess the patient and suction if secretions are present
11.Med-surg: neuro, endocrine & renalMedium
A patient with multiple sclerosis says their symptoms get worse after a hot bath. What should the nurse explain?
- AThis shows that the disease has entered a new progressive stage
- BThey should take very cold baths to reverse the damage
- CHeat can briefly worsen MS symptoms, which settle when they cool down
- DHot baths cause new areas of damage in the brain
12.Med-surg: neuro, endocrine & renalHard
A patient with CKD has a potassium of 6.5 mmol/L. Which medicine combination is the most likely contributor?
- AFurosemide, salbutamol and insulin
- BParacetamol (acetaminophen), omeprazole and senna
- CRamipril, spironolactone and trimethoprim
- DAmlodipine, simvastatin and aspirin
13.Med-surg: GI, perioperative & oncologyMedium
Why is the Lund and Browder chart preferred to the rule of nines for children?
- AIt is used only for burns of the hands
- BIt is faster to use than any other method of estimation
- CIt adjusts for body proportions that change with age
- DIt counts superficial burns as well
14.Med-surg: GI, perioperative & oncologyHard
A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?
- AProtamine sulfate on its own
- BProthrombin complex concentrate with IV vitamin K
- CMore warfarin to stabilise the INR
- DOral aspirin to balance the clotting system quickly
3Solutions
1.Prioritization & delegation
Answer: C · Potassium chloride by IV push
Why this is the answer
Potassium chloride must never be given by IV push, because a rapid dose can cause cardiac arrest. It is diluted and given slowly through an infusion pump.
C · Potassium chloride by IV push
2.Prioritization & delegation
Answer: C · “I can still eat aged cheese and cured salami.”
Why this is the answer
MAO inhibitors with tyramine-rich foods, such as aged cheese and cured meats, can cause a hypertensive crisis. Patients avoid these foods, check medicines with a pharmacist and report a severe headache.
C · “I can still eat aged cheese and cured salami.”
3.Infection control & patient safety
Answer: A · Write it down, read it back to confirm and report it to the provider promptly
Why this is the answer
Writing down and reading back critical results confirms they were heard correctly. The nurse then reports them promptly to the responsible provider and documents who was told and when.
A · Write it down, read it back to confirm and report it to the provider promptly
4.Infection control & patient safety
Answer: B · Lying face down (prone)
Why this is the answer
Restraining a person face down can restrict breathing and has caused deaths from positional asphyxia. Restrained patients are positioned to protect the airway and are watched closely.
B · Lying face down (prone)
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: D · An ionized calcium
Why this is the answer
Low albumin lowers total calcium without necessarily lowering the active, ionized calcium. Measuring ionized calcium directly is the most reliable way to decide whether treatment is needed.Checked against: Calcium - ionized · MedlinePlus (NIH) (2025); Calcium Blood Test · MedlinePlus (NIH) (2024)
7.Clinical nursing
Answer: C · Rotate injection sites to avoid lipohypertrophy
Why this is the answer
Rotating sites prevents fatty lumps that make absorption unpredictable. Cloudy insulins are mixed by gentle rolling, not shaking.
C · Rotate injection sites to avoid lipohypertrophy
8.Clinical nursing
Answer: B · Non-invasive ventilation
Why this is the answer
In hypercapnic respiratory failure from COPD that persists despite treatment, non-invasive ventilation (bilevel positive pressure) supports ventilation and lowers PaCO2. Stopping oxygen would cause dangerous hypoxia.
B · Non-invasive ventilation
9.Med-surg: cardiovascular & respiratory
Answer: D · Slowly and deeply while pressing the canister, then hold the breath
Why this is the answer
With a metered-dose inhaler, the patient breathes out, starts a slow deep breath, presses the canister at the start of it and then holds the breath for about 10 seconds. Coordination is difficult, which is why spacers are often used.
D · Slowly and deeply while pressing the canister, then hold the breath
10.Med-surg: cardiovascular & respiratory
Answer: D · Assess the patient and suction if secretions are present
Why this is the answer
High-pressure alarms are caused by secretions, coughing, biting the tube, kinked tubing or bronchospasm. With secretions heard, suctioning is the logical first step after a quick assessment. Low-pressure alarms suggest a leak or disconnection. Alarms must never be silenced without finding the cause.
D · Assess the patient and suction if secretions are present
11.Med-surg: neuro, endocrine & renal
Answer: C · Heat can briefly worsen MS symptoms, which settle when they cool down
Why this is the answer
Heat sensitivity (Uhthoff's phenomenon) is common in MS. A rise in body temperature slows conduction in demyelinated nerves and temporarily worsens symptoms. It is not a relapse, and the symptoms settle with cooling.
C · Heat can briefly worsen MS symptoms, which settle when they cool down
12.Med-surg: neuro, endocrine & renal
Answer: C · Ramipril, spironolactone and trimethoprim
Why this is the answer
ACE inhibitors and spironolactone reduce aldosterone effect, and trimethoprim blocks potassium secretion in the distal tubule. Together, in CKD, they can cause dangerous hyperkalaemia. Loop diuretics, salbutamol and insulin lower potassium.
C · Ramipril, spironolactone and trimethoprim
13.Med-surg: GI, perioperative & oncology
Answer: C · It adjusts for body proportions that change with age
Why this is the answer
The Lund and Browder chart gives different percentages for the head and legs at different ages, so it is more accurate in children and is also widely used in adults.
C · It adjusts for body proportions that change with age
14.Med-surg: GI, perioperative & oncology
Answer: B · Prothrombin complex concentrate with IV vitamin K
Why this is the answer
Major bleeding on warfarin is treated by stopping it and giving prothrombin complex concentrate for rapid reversal with IV vitamin K for a lasting effect. Protamine reverses heparin, not warfarin.
B · Prothrombin complex concentrate with IV vitamin K
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