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 with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?
- AEncourage a large meal to settle the stomach
- BCheck the blood glucose and ketones and contact the provider
- CWait until tomorrow to see if the vomiting settles
- DStop all insulin until the patient is able to eat normally again
2.Prioritization & delegationHard
Which patient needs airborne precautions rather than droplet precautions?
- AA child with pertussis (whooping cough)
- BAn adult with influenza
- CA child with chickenpox (varicella)
- DA teenager with mumps
3.Infection control & patient safetyMedium
Before a defibrillator shock is delivered, what must the person operating it do?
- AHold the patient’s hand to keep them still
- BAsk a colleague to hold the paddles in place
- CKeep the oxygen mask on the patient’s face, held against the chest
- DCall “all clear” and check that nobody is touching the patient or bed
4.Infection control & patient safetyHard
A patient has a rash, and both smallpox and chickenpox are considered. Which finding suggests smallpox?
- ALesions at different stages, most dense on the trunk
- BSmall crops of new lesions appearing over several days in a row
- CA rash that is very itchy and starts on the trunk
- DLesions all at the same stage, most dense on the face and limbs
5.Lab values & electrolytesMedium
How does the nurse start a 24-hour urine collection at 08:00?
- ACollect only the first urine passed on waking, and repeat this the next morning
- BHave the patient void and discard that urine, then save all urine until 08:00 the next day
- CSave the 08:00 urine as the first sample, then collect until 08:00 the next day
- DSave three samples spread across the day and discard all of the urine passed at night
6.Lab values & electrolytesHard
A lithium level of 1.0 mEq/L was drawn 2 hours after the patient’s morning dose, and the prescriber plans to raise the dose. What should the nurse point out?
- ALithium levels can be drawn at any time of day without affecting the result
- BThe level is too low, so a large increase is clearly safe
- CThe sample was taken too soon after the dose, so it is not a valid level
- DThe level is toxic, so lithium should be stopped for good
7.Clinical nursingMedium
Which side effect of regular opioids usually needs preventive treatment from the start?
- AConstipation
- BDiarrhoea
- CHigh blood pressure
- DExcessive hunger
8.Clinical nursingHard
Why are early surgery and early mobilisation recommended for older patients with a hip fracture?
- AThey reduce complications such as pneumonia, pressure ulcers and delirium
- BThey allow the bone to heal fully without any need for pain relief
- CThey mainly reduce the cost of the operation
- DThey make physiotherapy and rehabilitation unnecessary after discharge
9.Med-surg: cardiovascular & respiratoryMedium
Which patient is most typical of a primary spontaneous pneumothorax?
- AA middle-aged woman with high blood pressure
- BA child with a viral sore throat
- CA tall, thin young man who smokes
- DAn older woman with long-standing heart failure
10.Med-surg: cardiovascular & respiratoryHard
A one-way speaking valve is fitted to a patient's tracheostomy tube while the cuff is still inflated. What is the danger?
- AThe valve will humidify the air too much
- BThe patient cannot breathe out and may suffocate
- CThe patient will speak too loudly
- DThere is no danger, as the valve works with any cuff
11.Med-surg: neuro, endocrine & renalMedium
Which blood gas pattern is typical of acute kidney injury?
- ALow pH and high carbon dioxide only
- BLow pH and low bicarbonate
- CHigh pH and low carbon dioxide
- DHigh pH and high bicarbonate
12.Med-surg: neuro, endocrine & renalHard
A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?
- AThe kidneys clear less insulin, so it lasts longer
- BKidney disease makes the meter read too low
- CKidney disease makes the body resistant to insulin
- DThe patient is eating far more carbohydrate than before
13.Med-surg: GI, perioperative & oncologyMedium
Which electrolyte abnormality can contribute to a postoperative ileus?
- AHyperphosphataemia
- BHypernatraemia
- CHypokalaemia
- DHyperkalaemia
14.Med-surg: GI, perioperative & oncologyHard
In recovery, an awake and anxious patient cannot lift their head, and their breaths are shallow and weak. What is the most likely cause?
- ANormal tiredness after surgery
- BA simple panic attack
- COpioid overdose with pinpoint pupils
- DResidual neuromuscular blockade
3Solutions
1.Prioritization & delegation
Answer: B · Check the blood glucose and ketones and contact the provider
Why this is the answer
Vomiting in type 1 diabetes can lead quickly to diabetic ketoacidosis. Glucose and ketones are checked and the provider is contacted; insulin is usually not stopped completely during illness.
B · Check the blood glucose and ketones and contact the provider
2.Prioritization & delegation
Answer: C · A child with chickenpox (varicella)
Why this is the answer
Varicella spreads by the airborne route (and contact), so it needs an airborne infection isolation room. Influenza, pertussis and mumps are spread mainly by droplets.
C · A child with chickenpox (varicella)
3.Infection control & patient safety
Answer: D · Call “all clear” and check that nobody is touching the patient or bed
Why this is the answer
Anyone touching the patient or bed could receive the shock. The operator announces “clear” and looks to confirm that nobody is in contact, and oxygen is moved away from the chest.
D · Call “all clear” and check that nobody is touching the patient or bed
4.Infection control & patient safety
Answer: D · Lesions all at the same stage, most dense on the face and limbs
Why this is the answer
In smallpox, lesions develop at the same stage in any one area and are densest on the face and extremities. In chickenpox, crops appear at different stages and are densest on the trunk.
D · Lesions all at the same stage, most dense on the face and limbs
5.Lab values & electrolytes
Answer: B · Have the patient void and discard that urine, then save all urine until 08:00 the next day
Why this is the answer
The collection starts with an empty bladder, so the first void is discarded and the time recorded. All urine for the next 24 hours is saved, including a final void at the end time. If urine is discarded by mistake, the collection usually has to restart.Checked against: Urine 24-hour volume · MedlinePlus (NIH) (2025)
B · Have the patient void and discard that urine, then save all urine until 08:00 the next day
6.Lab values & electrolytes
Answer: C · The sample was taken too soon after the dose, so it is not a valid level
Why this is the answer
Lithium levels are standardized at about 12 hours after the last dose, usually just before the morning dose. A sample 2 hours after a dose catches the absorption peak and is not comparable with the target range, so the dose should not be changed on it.
C · The sample was taken too soon after the dose, so it is not a valid level
7.Clinical nursing
Answer: A · Constipation
Why this is the answer
Opioids slow gut movement, and constipation persists with long-term use. A regular laxative is usually prescribed together with the opioid.
8.Clinical nursing
Answer: A · They reduce complications such as pneumonia, pressure ulcers and delirium
Why this is the answer
Delayed surgery and immobility increase the risk of chest infection, VTE, pressure ulcers, delirium and loss of independence. Guidelines recommend surgery within about 24–48 hours of admission (UK guidance: the day of or day after) and mobilisation soon after.
A · They reduce complications such as pneumonia, pressure ulcers and delirium
9.Med-surg: cardiovascular & respiratory
Answer: C · A tall, thin young man who smokes
Why this is the answer
Primary spontaneous pneumothorax usually occurs in tall, thin young men, often smokers, when small apical blebs rupture. Secondary pneumothorax occurs in people with lung disease such as COPD and tends to be more serious.
C · A tall, thin young man who smokes
10.Med-surg: cardiovascular & respiratory
Answer: B · The patient cannot breathe out and may suffocate
Why this is the answer
A speaking valve opens on inspiration and closes on expiration, so exhaled air must pass around the tube and up through the larynx. If the cuff is inflated, air cannot escape, causing air trapping and respiratory arrest. The cuff must be fully deflated first.
B · The patient cannot breathe out and may suffocate
11.Med-surg: neuro, endocrine & renal
Answer: B · Low pH and low bicarbonate
Why this is the answer
Failing kidneys cannot excrete acid or regenerate bicarbonate, causing a metabolic acidosis with low pH and low bicarbonate. The patient may breathe faster to blow off CO2 as compensation.
B · Low pH and low bicarbonate
12.Med-surg: neuro, endocrine & renal
Answer: A · The kidneys clear less insulin, so it lasts longer
Why this is the answer
The kidneys clear a large share of insulin. As kidney function falls, insulin stays in the blood longer and some oral agents build up, so hypos increase. Insulin doses often need to be reduced.
A · The kidneys clear less insulin, so it lasts longer
13.Med-surg: GI, perioperative & oncology
Answer: C · Hypokalaemia
Why this is the answer
Low potassium impairs smooth muscle contraction and is a common correctable contributor to ileus. Magnesium and other electrolytes are also checked and corrected.
14.Med-surg: GI, perioperative & oncology
Answer: D · Residual neuromuscular blockade
Why this is the answer
Remaining muscle relaxant causes weakness, poor head lift and shallow breathing in an awake patient. The nurse supports breathing, gives oxygen and calls the anaesthetist, who may give a reversal agent.
D · Residual neuromuscular blockade
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