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
Several patients on a gastroenterology unit need care. Which patient should the nurse see first?
- ACrohn disease, waiting to be taken down for a scheduled CT scan
- BTwo hours after a colonoscopy: rigid abdomen and severe new pain
- CUlcerative colitis, asking about diet changes for home
- DLong-standing back pain, asking for the usual analgesic
2.Prioritization & delegationHard
A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?
- A“I will check with the pharmacist before cold remedies.”
- B“I will avoid tap beer and red wine.”
- C“A sudden severe headache is a warning sign.”
- D“I can still eat aged cheese and cured salami.”
3.Infection control & patient safetyMedium
A patient has botulism after eating contaminated food. Which precautions are needed?
- ADroplet precautions
- BAirborne precautions
- CStandard precautions
- DContact precautions
4.Infection control & patient safetyHard
A patient with severe dementia gets out of bed alone at night and has fallen twice. Which plan is most appropriate?
- AA sedative every night to keep the patient in bed
- BFour raised side rails, with the door closed at night for quiet
- CTying the patient into the chair overnight
- DLow bed, bed alarm, toileting rounds, night light and nonslip socks
5.Lab values & electrolytesMedium
A patient is on an IV insulin infusion protocol in the ICU. How often is the blood glucose usually checked?
- AAbout every hour
- BOnce a day before breakfast
- COnly if symptoms occur
- DOnce every 12 hours
6.Lab values & electrolytesHard
A stable patient's hemoglobin has been 13–14 g/dL for days. Today's result is 8.2 g/dL, but the patient feels well, the vital signs are normal and there is no bleeding. What should the nurse suspect first?
- AA normal day-to-day variation in Hb
- BA sample taken from the wrong patient
- CAcute bone marrow failure overnight
- DSudden massive internal bleeding
7.Clinical nursingMedium
Which adverse effects should be monitored for in a patient receiving IV gentamicin?
- AKidney damage and hearing loss
- BConstipation and urinary retention
- CHair loss and weight gain
- DHyperglycaemia and tremor
8.Clinical nursingHard
An older patient's blood pressure is 142/80 mmHg lying and 116/72 mmHg after standing for three minutes, and they feel dizzy. What does this show?
- AWhite coat hypertension
- BHypertensive emergency
- CPostural hypotension
- DNormal blood pressure variation
9.Med-surg: cardiovascular & respiratoryMedium
A patient has had atrial fibrillation for more than 48 hours and is listed for elective cardioversion. Why is anticoagulation needed beforehand?
- AAnticoagulants convert AF back to sinus rhythm
- BAtrial clots may be dislodged when sinus rhythm returns
- CAnticoagulants reduce the electrical energy needed for the shock
- DAnticoagulants make the shock less painful
10.Med-surg: cardiovascular & respiratoryHard
A patient on three blood pressure drugs still has high readings at every visit. What should the nurse check first?
- AWhether the readings should be ignored
- BWhether a fourth drug can be added at today's appointment
- CWhether the patient needs surgery on the renal arteries
- DWhether the patient is taking the medicines as prescribed
11.Med-surg: neuro, endocrine & renalMedium
Why is all urine strained in a patient with suspected kidney stones?
- ATo remove blood clots before testing
- BTo stop the stone from blocking the toilet
- CTo catch the stone so it can be analysed
- DTo measure the urine volume more accurately
12.Med-surg: neuro, endocrine & renalHard
A haemodialysis patient asks why fluid between sessions must be limited. Which explanation is correct?
- AFluid restriction is mainly to shorten the time spent on the machine
- BDrinking water makes the dialysis remove too much potassium from the blood
- CExtra fluid weakens the fistula wall and makes it more likely to burst
- DExcess fluid builds up, raising BP and causing breathlessness and cramps on dialysis
13.Med-surg: GI, perioperative & oncologyMedium
Which score is used to assess risk in an upper GI bleed before endoscopy?
- AGlasgow-Blatchford score
- BWaterlow pressure ulcer risk score
- CWells score for DVT
- DGlasgow Coma Scale
14.Med-surg: GI, perioperative & oncologyHard
Which group of signs suggests that a patient is entering the last days of life?
- AClearer thinking and increased movement
- BReduced intake, mottled skin and changes in breathing
- CRising appetite, more energy and normal skin colour and warmth
- DHigh blood pressure and very fast weight gain
3Solutions
1.Prioritization & delegation
Answer: B · Two hours after a colonoscopy: rigid abdomen and severe new pain
Why this is the answer
A rigid abdomen with severe pain after colonoscopy suggests bowel perforation and peritonitis, a surgical emergency. The other patients have stable, chronic or routine needs.
B · Two hours after a colonoscopy: rigid abdomen and severe new pain
2.Prioritization & delegation
Answer: D · “I can still eat aged cheese and cured salami.”
Why this is the answer
MAO inhibitors with tyramine-rich foods, such as aged cheese and cured meats, can cause a hypertensive crisis. Patients avoid these foods, check medicines with a pharmacist and report a severe headache.
D · “I can still eat aged cheese and cured salami.”
3.Infection control & patient safety
Answer: C · 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: D · Low bed, bed alarm, toileting rounds, night light and nonslip socks
Why this is the answer
Combined measures reduce falls best: a low bed, alarms, scheduled rounding and toileting, good lighting and nonslip footwear. Four side rails, routine sedatives and restraint increase injury risk.
D · Low bed, bed alarm, toileting rounds, night light and nonslip socks
5.Lab values & electrolytes
Answer: A · About every hour
Why this is the answer
IV insulin acts quickly and has a short half-life, so glucose is usually checked hourly (or as the protocol specifies) and the rate adjusted. This reduces the risk of hypoglycemia and keeps glucose in the target range.
6.Lab values & electrolytes
Answer: B · A sample taken from the wrong patient
Why this is the answer
A sudden large change with no clinical change suggests a specimen error, such as wrong blood in the tube or dilution with IV fluid. The nurse assesses the patient, informs the provider and arranges a repeat sample with careful identification, while staying alert for true bleeding.
B · A sample taken from the wrong patient
7.Clinical nursing
Answer: A · Kidney damage and hearing loss
Why this is the answer
Gentamicin is nephrotoxic and ototoxic. Blood levels and renal function are monitored, and any tinnitus, dizziness or hearing change is reported.
A · Kidney damage and hearing loss
8.Clinical nursing
Answer: C · Postural hypotension
Why this is the answer
A fall in systolic pressure of 20 mmHg or more (here 26 mmHg) on standing, especially with symptoms, indicates postural hypotension. Causes include medicines, dehydration and autonomic problems.
9.Med-surg: cardiovascular & respiratory
Answer: B · Atrial clots may be dislodged when sinus rhythm returns
Why this is the answer
After 48 hours of AF, atrial thrombus may be present. Restoring organised contraction can expel it and cause a stroke. Patients are usually anticoagulated for at least three weeks before (or a transoesophageal echo excludes clot) and for at least four weeks afterwards.
B · Atrial clots may be dislodged when sinus rhythm returns
10.Med-surg: cardiovascular & respiratory
Answer: D · Whether the patient is taking the medicines as prescribed
Why this is the answer
Before labelling hypertension as resistant, adherence, measurement technique, white-coat effect and interacting substances (NSAIDs, decongestants, alcohol, liquorice) should be checked. Side effects, cost and complex regimens are common reasons for missed doses.
D · Whether the patient is taking the medicines as prescribed
11.Med-surg: neuro, endocrine & renal
Answer: C · To catch the stone so it can be analysed
Why this is the answer
A passed stone can be sent for analysis. Its composition guides diet and drug advice to prevent recurrence. Straining also confirms that the stone has passed.
C · To catch the stone so it can be analysed
12.Med-surg: neuro, endocrine & renal
Answer: D · Excess fluid builds up, raising BP and causing breathlessness and cramps on dialysis
Why this is the answer
Patients with little residual urine output accumulate fluid between sessions. Large gains cause hypertension, pulmonary oedema and heart strain, and removing large volumes quickly during dialysis causes hypotension and cramps. Restricting fluid and salt (which drives thirst) keeps gains manageable.
D · Excess fluid builds up, raising BP and causing breathlessness and cramps on dialysis
13.Med-surg: GI, perioperative & oncology
Answer: A · Glasgow-Blatchford score
Why this is the answer
The Glasgow-Blatchford score uses urea, haemoglobin, systolic blood pressure, pulse, melaena, syncope, liver disease and heart failure to identify patients who need intervention. The full Rockall score is used after endoscopy.
A · Glasgow-Blatchford score
14.Med-surg: GI, perioperative & oncology
Answer: B · Reduced intake, mottled skin and changes in breathing
Why this is the answer
Signs include increasing drowsiness, reduced intake, mottled cool peripheries, changes in breathing such as pauses, and noisy secretions. Recognising them allows care to focus on comfort and family support.
B · Reduced intake, mottled skin and changes in breathing
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