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 Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?
- ARh immunoglobulin within 72 hours
- BNo treatment is needed
- CA dose of the hepatitis B vaccine instead
- DVitamin K to the mother
2.Prioritization & delegationHard
Which nursing approach may raise intracranial pressure in a patient with a head injury?
- AKeeping the room calm and quiet
- BDoing suctioning, turning and bathing all at the same time
- CSpacing out care with rest periods in between activities
- DKeeping the head in line with the body
3.Infection control & patient safetyMedium
A patient has botulism after eating contaminated food. Which precautions are needed?
- AContact precautions
- BDroplet precautions
- CAirborne precautions
- DStandard precautions
4.Infection control & patient safetyHard
A patient on a general ward for two days is found to have smear-positive pulmonary TB. What should the nurse do besides moving the patient to an airborne isolation room?
- AInform infection prevention so exposed patients and staff can be identified and followed up
- BNothing more, because the patient has now been isolated
- CTell all the exposed patients to start TB drugs at once, before any testing
- DClose the ward to all new admissions for a full year
5.Lab values & electrolytesMedium
A test has very high sensitivity for a disease. What does a negative result mean?
- AThe result cannot be used, because sensitivity is high
- BThe disease is certain, so treatment should begin
- CThe patient must have a different disease instead
- DThe disease is unlikely, so it helps rule it out
6.Lab values & electrolytesHard
At the start of a shift, the nurse reviews four new results. Which patient needs attention first?
- AGlucose 180 mg/dL (10 mmol/L) after a meal in a patient with diabetes
- BSodium 119 mEq/L in a patient with new confusion and vomiting
- CPotassium 5.2 mEq/L in a patient with stable chronic kidney disease
- DHemoglobin 11.0 g/dL (110 g/L) in a patient with rheumatoid arthritis
7.Clinical nursingMedium
A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?
- ADelaying pain relief until a diagnosis is confirmed
- BApplying cold packs to the painful areas
- CRestricting oral fluids
- DGiving prompt, effective analgesia
8.Clinical nursingHard
In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?
- AIrregular breathing pauses
- BA slow pulse with high blood pressure
- CA fixed, dilated pupil on both sides
- DA change in level of consciousness
9.Med-surg: cardiovascular & respiratoryMedium
A patient is going home with a 24-hour Holter monitor. Which instruction is most important?
- AKeep a diary of symptoms and activities with the times
- BRemove the monitor whenever symptoms occur and restart it
- CShower as normal with the monitor on
- DStay in bed for the full 24 hours so the trace is clear
10.Med-surg: cardiovascular & respiratoryHard
After a fall onto the chest, part of a patient's chest wall moves inward when they breathe in and outward when they breathe out. What does this indicate?
- AA large pleural effusion pressing on the chest wall
- BA flail chest from ribs broken in more than one place
- CNormal chest movement caused by pain on breathing
- DA single simple rib fracture with no lung injury
11.Med-surg: neuro, endocrine & renalMedium
A patient has had a calcium oxalate kidney stone. Which advice best helps prevent another?
- ADrink plenty of fluid so the urine stays pale
- BDrink only a little to avoid diluting the urine
- CCut all calcium out of the diet
- DTake extra vitamin C supplements
12.Med-surg: neuro, endocrine & renalHard
Which task for a patient with a urinary catheter can the nurse delegate to a healthcare assistant (nursing assistant)?
- ADeciding whether the catheter can be removed
- BEmptying the drainage bag and recording the volume
- CAssessing a patient whose irrigation is not draining
- DTeaching self-catheterisation for the first time
13.Med-surg: GI, perioperative & oncologyMedium
What does "neoadjuvant" treatment mean?
- ATreatment given only for pain relief
- BTreatment that is given only after the cancer has already spread
- CTreatment before the main treatment, often to shrink the tumour
- DTreatment that is given instead of any surgery
14.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient after a laparoscopic fundoplication for reflux. Which statement shows a need for further teaching?
- A"I'll eat soft, moist food at first and chew it well."
- B"Fizzy drinks will help me bring up wind after meals."
- C"I should eat smaller meals for a while after the operation."
- D"Some difficulty swallowing can happen in the early weeks."
3Solutions
1.Prioritization & delegation
Answer: A · Rh immunoglobulin within 72 hours
Why this is the answer
Rh immunoglobulin given within 72 hours of birth prevents the mother from forming anti-D antibodies, which could harm a future Rh-positive baby.
A · Rh immunoglobulin within 72 hours
2.Prioritization & delegation
Answer: B · Doing suctioning, turning and bathing all at the same time
Why this is the answer
Clustering several stimulating activities can cause a sustained rise in intracranial pressure. Spacing care, keeping the neck straight and a calm environment help keep it down.
B · Doing suctioning, turning and bathing all at the same time
3.Infection control & patient safety
Answer: D · Standard precautions
Why this is the answer
Botulism is caused by a toxin and does not spread from person to person, so standard precautions are used. Suspected cases are reported to public health at once.
4.Infection control & patient safety
Answer: A · Inform infection prevention so exposed patients and staff can be identified and followed up
Why this is the answer
Infection prevention and public health carry out a contact investigation to identify and screen people exposed while the patient was not isolated. Treatment of contacts depends on their test results.
A · Inform infection prevention so exposed patients and staff can be identified and followed up
5.Lab values & electrolytes
Answer: D · The disease is unlikely, so it helps rule it out
Why this is the answer
Sensitivity is the proportion of people with the disease who test positive. A highly sensitive test has few false negatives, so a negative result helps rule the disease out (the D-dimer is an example). Specificity relates to ruling in.
D · The disease is unlikely, so it helps rule it out
6.Lab values & electrolytes
Answer: B · Sodium 119 mEq/L in a patient with new confusion and vomiting
Why this is the answer
Severe hyponatremia with confusion and vomiting suggests cerebral edema and can progress to seizures and coma. The other results are mildly abnormal and expected for those conditions, so they are less urgent.Checked against: Low blood sodium - Medical Encyclopedia · MedlinePlus (NIH) (2025); Sodium Blood Test · MedlinePlus (NIH) (2024)
B · Sodium 119 mEq/L in a patient with new confusion and vomiting
7.Clinical nursing
Answer: D · Giving prompt, effective analgesia
Why this is the answer
A sickle cell crisis needs rapid analgesia, often opioids, within a short target time, plus hydration, oxygen if hypoxic, warmth and monitoring for complications. Cold can trigger more sickling.
D · Giving prompt, effective analgesia
8.Clinical nursing
Answer: D · A change in level of consciousness
Why this is the answer
Subtle changes in consciousness, such as restlessness, confusion or a falling GCS, are often the first signs. Pupil changes and Cushing's triad (hypertension, bradycardia, irregular breathing) are late signs.
D · A change in level of consciousness
9.Med-surg: cardiovascular & respiratory
Answer: A · Keep a diary of symptoms and activities with the times
Why this is the answer
A Holter monitor records the ECG continuously during normal daily life. A diary of symptoms and activities lets the reviewer match symptoms such as palpitations or dizziness to the rhythm. The device is kept dry unless it is designed to be waterproof.
A · Keep a diary of symptoms and activities with the times
10.Med-surg: cardiovascular & respiratory
Answer: B · A flail chest from ribs broken in more than one place
Why this is the answer
A flail segment occurs when adjacent ribs are fractured in two or more places, so the segment moves paradoxically. It is often associated with lung contusion and respiratory failure. Management includes oxygen, strong analgesia and sometimes ventilation or surgical fixation.
B · A flail chest from ribs broken in more than one place
11.Med-surg: neuro, endocrine & renal
Answer: A · Drink plenty of fluid so the urine stays pale
Why this is the answer
High fluid intake is the most important measure for preventing stones. Dietary calcium is usually not restricted, because it binds oxalate in the gut. High-dose vitamin C can increase oxalate.
A · Drink plenty of fluid so the urine stays pale
12.Med-surg: neuro, endocrine & renal
Answer: B · Emptying the drainage bag and recording the volume
Why this is the answer
Emptying and recording urine volume is routine and can be delegated to trained staff. Decisions about removal, assessment of a possible blockage and first-time teaching need the registered nurse.
B · Emptying the drainage bag and recording the volume
13.Med-surg: GI, perioperative & oncology
Answer: C · Treatment before the main treatment, often to shrink the tumour
Why this is the answer
Neoadjuvant chemotherapy or radiotherapy is given before surgery to shrink the tumour, which may make surgery easier or allow less extensive surgery. Adjuvant therapy follows surgery.
C · Treatment before the main treatment, often to shrink the tumour
14.Med-surg: GI, perioperative & oncology
Answer: B · "Fizzy drinks will help me bring up wind after meals."
Why this is the answer
Fundoplication wraps the stomach around the lower oesophagus, so belching may be hard and gas bloat is common; fizzy drinks make it worse. Soft food, small meals and good chewing help while early swelling settles.
B · "Fizzy drinks will help me bring up wind after meals."
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