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 finding is an early sign of compartment syndrome in a patient with a lower leg fracture?
- AMild bruising around the fracture site on the second day
- BA strong pedal pulse with warm, pink toes and pain that settles with analgesia
- CPain out of proportion to the injury that worsens when the toes are stretched
- DItching under the cast during the first week after it was applied
2.Prioritization & delegationHard
A nurse is caring for four patients. Who can be safely assigned to the nursing assistant for routine care?
- AA patient with a new chest tube placed an hour ago
- BA patient five days after a stroke who needs help with bathing and has stable vital signs
- CA patient returning from surgery who needs the first postoperative assessment
- DA patient with a blood glucose of 52 mg/dL (2.9 mmol/L) who is sweating
3.Infection control & patient safetyMedium
A patient cannot bear weight and cannot help with transfers. Which method is safest to move the patient from bed to chair?
- AA mechanical lift used by enough trained staff
- BTwo nurses lifting the patient under the arms
- CAsking the patient to stand and try their best
- DOne nurse doing a standing pivot transfer
4.Infection control & patient safetyHard
A nurse working with a patient on contact precautions realizes the gown has a tear at the sleeve. What should the nurse do?
- AMove away from the patient, remove the PPE safely at the doorway, clean hands and re-gown
- BContinue working, since the tear is small and only on the sleeve
- CPut a second gown on top of the torn one
- DCover the tear with a strip of tape and carry on
5.Lab values & electrolytesMedium
A patient with iron-deficiency anemia started oral iron. Which result is usually the earliest sign that treatment is working?
- AA fall in the mean cell volume (MCV)
- BA rise in the reticulocyte count
- CA fall in the white cell count
- DA rise in the platelet count
6.Lab values & electrolytesHard
A patient with SIADH is on fluid restriction. Which task can the RN delegate to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?
- ADeciding when to recheck the sodium level
- BAssessing the patient for new confusion
- CMeasuring and recording intake and output
- DTeaching the reasons for fluid restriction
7.Clinical nursingMedium
A patient with MRSA colonisation is admitted. Which precautions are appropriate?
- ANo precautions are needed for colonisation
- BAirborne precautions with an FFP3 respirator mask for all staff
- CContact precautions with gloves, apron and good hand hygiene
- DIsolation in a negative-pressure room for six months
8.Clinical nursingHard
Which feature best distinguishes delirium from dementia?
- ADelirium is permanent, while dementia is reversible
- BDementia always causes visual hallucinations
- CDelirium only affects people under 50, while dementia affects older people
- DDelirium starts suddenly and fluctuates, while dementia develops gradually
9.Med-surg: cardiovascular & respiratoryMedium
A 70 kg patient has passed 20 mL of urine per hour for the last three hours. How should this be interpreted?
- ABelow 0.5 mL/kg/h, suggesting poor kidney perfusion
- BNormal, because any measurable urine output is reassuring
- CNormal, because the target is 0.1 mL/kg/h
- DHigh, suggesting fluid overload that needs a diuretic
10.Med-surg: cardiovascular & respiratoryHard
A patient is going home after a spontaneous pneumothorax treated with a chest drain. Which advice is correct?
- AExpect it never to happen again, so no follow-up is needed
- BStop smoking and do not fly until a doctor confirms full resolution
- CTake up scuba diving to strengthen the lungs
- DFly home as soon as possible so they can recover in comfort there
11.Med-surg: neuro, endocrine & renalMedium
In the first trimester of pregnancy, why is propylthiouracil often preferred to carbimazole for hyperthyroidism?
- APropylthiouracil works faster than any other drug
- BPropylthiouracil has no side effects at all
- CCarbimazole cannot cross into the mother's blood
- DCarbimazole has a higher risk of birth defects early on
12.Med-surg: neuro, endocrine & renalHard
A patient with SIADH is taught about a fluid restriction. Which statement shows a need for further teaching?
- A"I will count all drinks, including soup, in my daily total."
- B"I will weigh myself every morning."
- C"I will report any headaches or confusion."
- D"If I feel thirsty, I can drink as much water as I like."
13.Med-surg: GI, perioperative & oncologyMedium
When is cold therapy most useful for pain?
- AOver numb areas where sensation is lost
- BFor long-term muscle stiffness, applied continuously for several hours
- CSoon after an acute soft tissue injury, to reduce swelling
- DDirectly on skin with poor circulation
14.Med-surg: GI, perioperative & oncologyHard
A bag of parenteral nutrition runs out and the next one will not arrive for several hours. Which risk should the nurse anticipate?
- ASevere hyperkalaemia
- BAcute urinary retention
- CRebound hypoglycaemia
- DRaised intracranial pressure
3Solutions
1.Prioritization & delegation
Answer: C · Pain out of proportion to the injury that worsens when the toes are stretched
Why this is the answer
The earliest sign is severe pain that is not relieved by usual analgesia and worsens on passive stretch. Loss of pulse is a late sign, so the nurse reports pain early.
C · Pain out of proportion to the injury that worsens when the toes are stretched
2.Prioritization & delegation
Answer: B · A patient five days after a stroke who needs help with bathing and has stable vital signs
Why this is the answer
A stable patient who needs help with activities of daily living is suitable for routine care by an assistant. A new chest tube, symptomatic hypoglycemia and the first postoperative assessment need a licensed nurse.
B · A patient five days after a stroke who needs help with bathing and has stable vital signs
3.Infection control & patient safety
Answer: A · A mechanical lift used by enough trained staff
Why this is the answer
For a patient who cannot bear weight or help, a mechanical lift prevents injury to both patient and staff. Lifting under the arms can injure the shoulders, and pivot transfers need weight bearing.
A · A mechanical lift used by enough trained staff
4.Infection control & patient safety
Answer: A · Move away from the patient, remove the PPE safely at the doorway, clean hands and re-gown
Why this is the answer
Torn PPE allows contamination of skin and clothing. When it is safe, the nurse moves away from the patient, removes PPE in the correct order at the doorway or in the anteroom, cleans their hands and puts on new PPE.
A · Move away from the patient, remove the PPE safely at the doorway, clean hands and re-gown
5.Lab values & electrolytes
Answer: B · A rise in the reticulocyte count
Why this is the answer
Once iron is available, the marrow releases more young red cells, so the reticulocyte count rises within about 1–2 weeks. The hemoglobin rises more slowly over weeks, and iron stores take months to refill.Checked against: Reticulocyte Count · MedlinePlus (NIH) (2024)
B · A rise in the reticulocyte count
6.Lab values & electrolytes
Answer: C · Measuring and recording intake and output
Why this is the answer
UAP can measure and record intake and output and weigh the patient, then report the values to the RN. Assessing mental status, teaching and making decisions about laboratory monitoring need nursing judgment and remain with the RN.
C · Measuring and recording intake and output
7.Clinical nursing
Answer: C · Contact precautions with gloves, apron and good hand hygiene
Why this is the answer
MRSA is spread mainly by direct and indirect contact, so contact precautions, isolation where possible and strict hand hygiene limit transmission.
C · Contact precautions with gloves, apron and good hand hygiene
8.Clinical nursing
Answer: D · Delirium starts suddenly and fluctuates, while dementia develops gradually
Why this is the answer
Delirium develops over hours to days, with fluctuating attention and consciousness, and is often reversible when the cause is treated. Dementia is a gradual, progressive decline. Patients with dementia are at higher risk of delirium.
D · Delirium starts suddenly and fluctuates, while dementia develops gradually
9.Med-surg: cardiovascular & respiratory
Answer: A · Below 0.5 mL/kg/h, suggesting poor kidney perfusion
Why this is the answer
A urine output below about 0.5 mL/kg/h (35 mL/h for 70 kg) for several hours is oliguria and may indicate hypovolaemia, shock or acute kidney injury. It should be reported along with the other observations, and the catheter checked for blockage.
A · Below 0.5 mL/kg/h, suggesting poor kidney perfusion
10.Med-surg: cardiovascular & respiratory
Answer: B · Stop smoking and do not fly until a doctor confirms full resolution
Why this is the answer
Patients should not fly until the pneumothorax has resolved on X-ray, often with an extra waiting period. Diving is usually avoided permanently unless definitive surgery has been done. Smoking increases recurrence, which is common, so patients learn to seek help for new breathlessness or chest pain.
B · Stop smoking and do not fly until a doctor confirms full resolution
11.Med-surg: neuro, endocrine & renal
Answer: D · Carbimazole has a higher risk of birth defects early on
Why this is the answer
Carbimazole is linked to congenital abnormalities when used in early pregnancy, so propylthiouracil is often used in the first trimester. Propylthiouracil can cause serious liver injury, so it is not preferred at other times.
D · Carbimazole has a higher risk of birth defects early on
12.Med-surg: neuro, endocrine & renal
Answer: D · "If I feel thirsty, I can drink as much water as I like."
Why this is the answer
In SIADH, the body keeps too much water. Drinking freely when thirsty would lower the sodium further. All fluids count towards the restriction. Daily weights and reporting neurological symptoms are correct.
D · "If I feel thirsty, I can drink as much water as I like."
13.Med-surg: GI, perioperative & oncology
Answer: C · Soon after an acute soft tissue injury, to reduce swelling
Why this is the answer
Cold reduces swelling, bleeding and nerve conduction in acute injuries. It is wrapped and applied for short periods and avoided on areas with poor circulation or sensation. Heat is better for muscle spasm and stiffness.
C · Soon after an acute soft tissue injury, to reduce swelling
14.Med-surg: GI, perioperative & oncology
Answer: C · Rebound hypoglycaemia
Why this is the answer
Stopping PN suddenly can cause hypoglycaemia because insulin levels stay high for a while. Glucose is monitored, and a glucose infusion may be given according to local policy.
C · Rebound hypoglycaemia
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