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 blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?
- ANew chest pain or confusion suggesting organ damage
- BMild anxiety about the high reading on the monitor
- CA history of high blood pressure for ten years
- DForgetting to take the blood pressure tablet this morning
2.Prioritization & delegationHard
Four patients arrive at the emergency department at the same time. Who should be seen first?
- AAn older adult with weakness on one side that began 40 minutes ago
- BA child with a temperature of 39 °C who is alert and drinking
- CA young adult with a swollen, painful ankle after a fall on the stairs
- DAn adult with kidney stone pain of 9/10 and stable vital signs
3.Infection control & patient safetyMedium
A patient has patient-controlled analgesia (PCA). A family member presses the button while the patient sleeps. What should the nurse explain?
- AFamily can press it as long as they count the presses
- BPressing it while the patient sleeps prevents the pain from getting worse later
- CThe pump will always stop any overdose
- DOnly the patient should press it, because this keeps the system safe
4.Infection control & patient safetyHard
In US nursing practice, which task should the RN not assign to an LPN/LVN?
- AA dressing change on a healing surgical wound that has no signs of infection
- BReinforcing hand hygiene teaching that the RN has already given
- CGiving scheduled oral antibiotics to a stable patient
- DThe initial admission assessment of a new patient with suspected sepsis
5.Lab values & electrolytesMedium
A week after a splenectomy, a patient's platelet count is 650 × 10³/µL. What is the best interpretation?
- AA sign of iron overload from the surgery and transfusion
- BA sign of new leukemia that needs immediate chemotherapy
- CA laboratory error, because platelets fall after splenectomy
- DAn expected rise after splenectomy that increases clot risk
6.Lab values & electrolytesHard
A patient without symptoms has a TSH of 7.5 mIU/L on two occasions with a normal free T4. Which term fits best?
- ASubclinical hypothyroidism
- BSecondary hypothyroidism
- COvert primary hypothyroidism
- DSubclinical hyperthyroidism
7.Clinical nursingMedium
A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?
- ACategory 1
- BCategory 4
- CCategory 3
- DCategory 2
8.Clinical nursingHard
A patient with long-standing COPD has an arterial blood gas with pH 7.37, a raised PaCO2 and a raised bicarbonate. How is this best described?
- AUncompensated metabolic alkalosis
- BMixed metabolic and respiratory alkalosis
- CCompensated respiratory acidosis
- DAcute respiratory acidosis
9.Med-surg: cardiovascular & respiratoryMedium
Why is a non-selective beta-blocker such as propranolol usually avoided in a patient with asthma?
- AIt can cause bronchospasm by blocking beta-2 receptors
- BIt makes inhaled corticosteroids work too strongly
- CIt raises the heart rate sharply during an acute asthma attack
- DIt thickens airway mucus by drying the airways
10.Med-surg: cardiovascular & respiratoryHard
A patient taking apixaban for atrial fibrillation is booked for elective surgery. Which statement reflects correct practice?
- AIt is always continued up to the morning of the operation
- BPause it for a set time, based on bleeding risk and kidney function
- CIt is stopped and then reversed with oral vitamin K
- DStop it two weeks before surgery and replace it with warfarin
11.Med-surg: neuro, endocrine & renalMedium
Which criterion for acute kidney injury (KDIGO) relates to urine output?
- ABelow 0.5 mL/kg/h for 6 hours or more
- BBelow 2 mL/kg/h for 1 hour
- CBelow 1 L in 24 hours whatever the intake
- DAny change in the colour of the urine
12.Med-surg: neuro, endocrine & renalHard
A nurse teaches a wheelchair user with a spinal cord injury about skin care. Which statement shows a need for further teaching?
- A"I will shift my weight in the chair regularly."
- B"I will use a mirror to check my bottom and heels every day."
- C"I only need to check my skin when something hurts."
- D"I will keep my skin clean and dry."
13.Med-surg: GI, perioperative & oncologyMedium
Which infection control measure is correct for a patient with C. difficile diarrhoea?
- ANo special measures once antibiotics have started
- BA face mask for the patient and visitors only
- CA single room with its own toilet, and soap-and-water handwashing
- DA shared bay, as long as alcohol gel is used after every contact
14.Med-surg: GI, perioperative & oncologyHard
A patient is splashed in the eye with an alkaline cleaning product. What is the first action?
- AAsk the patient to rub the eye to clear it
- BCover the eye with a pad and wait for a doctor to examine it first
- CAdd a few drops of vinegar to neutralise it
- DIrrigate the eye at once with large volumes of water or saline
3Solutions
1.Prioritization & delegation
Answer: A · New chest pain or confusion suggesting organ damage
Why this is the answer
Severe hypertension becomes an emergency when there is acute organ damage, such as chest pain, neurological changes or kidney injury. It needs urgent, controlled lowering of the blood pressure.
A · New chest pain or confusion suggesting organ damage
2.Prioritization & delegation
Answer: A · An older adult with weakness on one side that began 40 minutes ago
Why this is the answer
Sudden one-sided weakness suggests a stroke, and treatment depends on how quickly it starts. Severe kidney stone pain needs prompt pain relief, but the patient is stable.
A · An older adult with weakness on one side that began 40 minutes ago
3.Infection control & patient safety
Answer: D · Only the patient should press it, because this keeps the system safe
Why this is the answer
PCA is safe because a patient who becomes drowsy stops pressing the button. When others press it (“PCA by proxy”), sedation and respiratory depression can occur.
D · Only the patient should press it, because this keeps the system safe
4.Infection control & patient safety
Answer: D · The initial admission assessment of a new patient with suspected sepsis
Why this is the answer
The initial assessment of a new, potentially unstable patient is an RN responsibility. LPNs/LVNs can give routine medications, perform routine procedures and reinforce teaching for stable patients.
D · The initial admission assessment of a new patient with suspected sepsis
5.Lab values & electrolytes
Answer: D · An expected rise after splenectomy that increases clot risk
Why this is the answer
The spleen stores about a third of the platelets. After splenectomy, the count often rises (reactive thrombocytosis), which can increase the risk of thrombosis. The count is monitored, and the patient is assessed for signs of clots.Checked against: Platelet count · MedlinePlus (NIH) (2025); Platelet Tests · MedlinePlus (NIH) (2024)
D · An expected rise after splenectomy that increases clot risk
6.Lab values & electrolytes
Answer: A · Subclinical hypothyroidism
Why this is the answer
A raised TSH with a normal free T4 is subclinical hypothyroidism; the pituitary is working harder to keep T4 normal. Overt hypothyroidism has a low free T4, and subclinical hyperthyroidism has a low TSH.Checked against: TSH (Thyroid-stimulating hormone) Test · MedlinePlus (NIH) (2024)
A · Subclinical hypothyroidism
7.Clinical nursing
Answer: B · Category 4
Why this is the answer
Category 4 involves full-thickness tissue loss with exposed bone, tendon or muscle. Category 3 is full-thickness skin loss without exposed bone or tendon. US (NPIAP) terminology calls these stages rather than categories.
8.Clinical nursing
Answer: C · Compensated respiratory acidosis
Why this is the answer
Chronic CO2 retention is offset by the kidneys retaining bicarbonate, bringing the pH back to normal. A normal pH with high PaCO2 and high bicarbonate is a compensated respiratory acidosis.
C · Compensated respiratory acidosis
9.Med-surg: cardiovascular & respiratory
Answer: A · It can cause bronchospasm by blocking beta-2 receptors
Why this is the answer
Beta-2 receptors in the airways mediate bronchodilation. Blocking them can trigger severe bronchospasm in asthma and also blunts the effect of salbutamol. Cardioselective beta-1 blockers are safer but still used with caution.
A · It can cause bronchospasm by blocking beta-2 receptors
10.Med-surg: cardiovascular & respiratory
Answer: B · Pause it for a set time, based on bleeding risk and kidney function
Why this is the answer
Because DOACs wear off within days, they are usually paused for a defined period before surgery (often 1–3 days) depending on the procedure's bleeding risk and renal function; bridging with heparin is generally not needed. Vitamin K does not reverse DOACs.
B · Pause it for a set time, based on bleeding risk and kidney function
11.Med-surg: neuro, endocrine & renal
Answer: A · 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.
A · Below 0.5 mL/kg/h for 6 hours or more
12.Med-surg: neuro, endocrine & renal
Answer: C · "I only need to check my skin when something hurts."
Why this is the answer
Patients usually cannot feel pain below the injury, so pain cannot warn them of pressure damage. They need daily skin checks, often with a mirror, regular pressure relief and good skin hygiene.
C · "I only need to check my skin when something hurts."
13.Med-surg: GI, perioperative & oncology
Answer: C · A single room with its own toilet, and soap-and-water handwashing
Why this is the answer
C. difficile forms spores that resist alcohol gel, so soap and water are used. Patients are isolated with their own toilet, staff use gloves and aprons, and the environment is cleaned with a sporicidal agent such as chlorine.
C · A single room with its own toilet, and soap-and-water handwashing
14.Med-surg: GI, perioperative & oncology
Answer: D · Irrigate the eye at once with large volumes of water or saline
Why this is the answer
Alkali burns can cause severe, deep eye damage. Immediate, prolonged irrigation, checking the pH, and urgent ophthalmology review are needed. Neutralising agents are not used.
D · Irrigate the eye at once with large volumes of water or saline
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