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 patient is most suitable for the nurse to assign to a nurse who has just finished orientation?
- AA patient on a continuous heparin infusion with rising aPTT values
- BA patient with stable cellulitis on scheduled IV antibiotics
- CA patient with sepsis whose blood pressure is falling
- DA patient with a new tracheostomy who needs frequent suctioning
2.Prioritization & delegationHard
A patient with a head injury and a leg fracture is being monitored. Which finding is the priority?
- ALeg pain of 6/10 despite the last dose of analgesia
- BThe Glasgow Coma Scale score falls from 15 to 12
- CThe patient asks for something to eat
- DA small graze on the elbow
3.Infection control & patient safetyMedium
Before inserting a peripheral IV, the nurse cleans the skin with chlorhexidine-alcohol. What should the nurse do next?
- ABlow on the site so it dries faster
- BFeel for the vein again with an ungloved finger
- CWipe it off with a dry gauze straight away
- DLet it dry fully and do not touch the site again
4.Infection control & patient safetyHard
A patient’s white cell differential shows a raised number of band (immature) neutrophils, called a “shift to the left”. What does this usually suggest?
- AAn allergic reaction
- BAn acute bacterial infection
- CA long-standing parasitic infection
- DA typical viral infection
5.Lab values & electrolytesMedium
A patient on a heparin infusion has blood in the urine and an aPTT far above the target. The nurse stops the infusion and informs the provider. Which antidote should the nurse anticipate?
- ANaloxone
- BVitamin K (phytonadione)
- CProtamine sulfate
- DCalcium gluconate
6.Lab values & electrolytesHard
Which set of results most strongly suggests hemolytic anemia?
- ALow hemoglobin, high MCV, low vitamin B12, normal bilirubin
- BLow hemoglobin, low platelets, low white cells, low reticulocytes
- CLow hemoglobin, low reticulocytes, low MCV, low ferritin
- DLow hemoglobin, high reticulocytes, high unconjugated bilirubin, high LDH
7.Clinical nursingMedium
Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?
- ATo check for a urinary tract infection that could delay ulcer healing
- BTo measure how deep the ulcer is and how much exudate it produces
- CTo work out the patient's fluid needs
- DTo exclude significant arterial disease, as compression could cut off blood flow
8.Clinical nursingHard
Why is a patient kept under observation for several hours after successful treatment of anaphylaxis?
- AThe patient must stay until all allergy tests are complete
- BSymptoms can return later in a biphasic reaction
- CAntihistamines cause dangerous drowsiness for 24 hours
- DAdrenaline always causes a heart attack hours later
9.Med-surg: cardiovascular & respiratoryMedium
A patient's blood pressure is 200/125 mmHg with new confusion and blurred vision. How should it usually be lowered?
- AWith titrated IV drugs, by up to about 25% in the first hour
- BAs fast as possible, to a normal value within minutes
- CWith a new oral tablet and review in a week
- DNot at all, because the brain now depends on the high pressure
10.Med-surg: cardiovascular & respiratoryHard
A nurse phones the doctor about a patient with pneumonia whose observations are worsening. Using SBAR, which statement is the clearest "recommendation"?
- A"I am calling about the patient in bed 6."
- B"He is 72 and was admitted yesterday with community-acquired pneumonia."
- C"His heart rate is 124/min, his BP is 88/50 mmHg and he is confused."
- D"I think he may have sepsis; please review him within 30 minutes."
11.Med-surg: neuro, endocrine & renalMedium
A patient's potassium stays low despite replacement. Which other level should be checked?
- AFerritin
- BBilirubin
- CAmylase
- DMagnesium
12.Med-surg: neuro, endocrine & renalHard
Four patients had a minor head injury with no loss of consciousness and a GCS of 15. Which one most needs a CT scan of the head?
- AA 40-year-old with a mild headache that is improving
- BA 25-year-old with a small scalp graze after a fall
- CA 30-year-old who bumped their head on a cupboard door
- DA 78-year-old who takes warfarin for atrial fibrillation
13.Med-surg: GI, perioperative & oncologyMedium
A patient with obstructive sleep apnoea is admitted for surgery. Which instruction is most appropriate?
- AStop all pain relief for the first three days
- BLie flat on their back for the first night
- CAvoid sleeping at all on the night after surgery
- DBring their CPAP machine to use after surgery
14.Med-surg: GI, perioperative & oncologyHard
A nurse teaches a patient after a colonoscopy with polyp removal. Which statement shows a need for further teaching?
- A"I'll report heavy bleeding from my bottom."
- B"I should report a fever or a swollen, painful abdomen."
- C"Severe abdominal pain is normal for a week afterwards."
- D"Some wind and bloating today is expected."
3Solutions
1.Prioritization & delegation
Answer: B · A patient with stable cellulitis on scheduled IV antibiotics
Why this is the answer
A newly oriented nurse is best given stable patients with predictable care. The other patients have changing or high-risk conditions that need more experience and close monitoring.
B · A patient with stable cellulitis on scheduled IV antibiotics
2.Prioritization & delegation
Answer: B · The Glasgow Coma Scale score falls from 15 to 12
Why this is the answer
A falling GCS suggests rising pressure inside the skull, which can be fatal, and needs urgent escalation. Fracture pain needs treatment too, but it does not threaten life in the same way.
B · The Glasgow Coma Scale score falls from 15 to 12
3.Infection control & patient safety
Answer: D · Let it dry fully and do not touch the site again
Why this is the answer
Chlorhexidine-alcohol must dry completely to kill organisms effectively. Touching the site after cleaning contaminates it, so the vein is located before prepping or with a sterile glove.
D · Let it dry fully and do not touch the site again
4.Infection control & patient safety
Answer: B · An acute bacterial infection
Why this is the answer
In acute bacterial infection, the bone marrow releases neutrophils before they mature, raising the proportion of bands. Allergies and parasites raise eosinophils, and viral infections more often raise lymphocytes.
B · An acute bacterial infection
5.Lab values & electrolytes
Answer: C · Protamine sulfate
Why this is the answer
Protamine sulfate binds heparin and reverses its effect quickly. Unfractionated heparin has a short half-life, so stopping the infusion is the first step. Vitamin K reverses warfarin, not heparin.
6.Lab values & electrolytes
Answer: D · Low hemoglobin, high reticulocytes, high unconjugated bilirubin, high LDH
Why this is the answer
When red cells break down early, hemoglobin is turned into unconjugated bilirubin and LDH is released, while the marrow increases reticulocytes. Option B fits iron deficiency, C fits B12 deficiency and D fits marrow failure.
D · Low hemoglobin, high reticulocytes, high unconjugated bilirubin, high LDH
7.Clinical nursing
Answer: D · To exclude significant arterial disease, as compression could cut off blood flow
Why this is the answer
ABPI compares ankle and arm blood pressures. A low result suggests arterial insufficiency, where compression could cause ischaemia; venous ulcers with adequate arterial supply are treated with compression.
D · To exclude significant arterial disease, as compression could cut off blood flow
8.Clinical nursing
Answer: B · Symptoms can return later in a biphasic reaction
Why this is the answer
Some patients have a second wave of symptoms hours after the first, called a biphasic reaction. Observation, an adrenaline auto-injector where indicated and allergy referral are part of safe discharge.
B · Symptoms can return later in a biphasic reaction
9.Med-surg: cardiovascular & respiratory
Answer: A · With titrated IV drugs, by up to about 25% in the first hour
Why this is the answer
A hypertensive emergency (severe hypertension with acute organ damage) is treated in a monitored setting with titrated IV drugs. Lowering the pressure too quickly can cause cerebral, coronary or renal ischaemia, so most guidance aims for a reduction of no more than about 25% in the first hour (with different targets for some conditions such as aortic dissection).
A · With titrated IV drugs, by up to about 25% in the first hour
10.Med-surg: cardiovascular & respiratory
Answer: D · "I think he may have sepsis; please review him within 30 minutes."
Why this is the answer
In SBAR, the recommendation states clearly what the nurse needs and how quickly, such as a review within a set time. The other statements belong to situation, background and assessment. Structured communication reduces delays in escalation.
D · "I think he may have sepsis; please review him within 30 minutes."
11.Med-surg: neuro, endocrine & renal
Answer: D · Magnesium
Why this is the answer
Hypomagnesaemia increases potassium loss in the urine and makes hypokalaemia hard to correct. Magnesium is checked and replaced as well.
12.Med-surg: neuro, endocrine & renal
Answer: D · A 78-year-old who takes warfarin for atrial fibrillation
Why this is the answer
Anticoagulation greatly increases the risk of an intracranial bleed after even a minor head injury, and older age adds to the risk. These patients have a low threshold for a CT scan, even when they appear well.
D · A 78-year-old who takes warfarin for atrial fibrillation
13.Med-surg: GI, perioperative & oncology
Answer: D · Bring their CPAP machine to use after surgery
Why this is the answer
OSA increases the risk of airway obstruction and respiratory depression after anaesthesia, especially with opioids. Using CPAP, careful opioid use, sitting up and close monitoring reduce this risk.
D · Bring their CPAP machine to use after surgery
14.Med-surg: GI, perioperative & oncology
Answer: C · "Severe abdominal pain is normal for a week afterwards."
Why this is the answer
Mild bloating and cramps from the air used are expected. Severe or worsening pain, fever, a distended abdomen or heavy rectal bleeding can mean perforation or haemorrhage and must be reported straight away.
C · "Severe abdominal pain is normal for a week afterwards."
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