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 taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?
- AEncourage the patient to cut down on salt and fluids
- BGive the dose with food to reduce the stomach upset
- CReassure the patient that a coarse tremor is expected at first
- DHold the next dose and report for an urgent lithium level
2.Prioritization & delegationHard
A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?
- ASay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret
- BTalk to the assistant privately, restate what must be reported and follow up closely
- CComplain about the assistant to the patients during care
- DStop delegating any tasks to the assistant for the rest of the year
3.Infection control & patient safetyMedium
A colleague has drawn up a medication and asks the nurse to give it to her patient. What should the nurse do?
- AGive it, and document that the colleague prepared it
- BGive it, because the colleague is experienced
- CGive it, as long as the syringe has a label with the drug name on it
- DDecline, and give only medications that the nurse prepared or checked personally
4.Infection control & patient safetyHard
While preparing an IV medication, a nurse sees that the syringe tip touched the medication tray after the cap came off. What should the nurse do?
- AWipe the tip with an alcohol swab and give the dose
- BGive the dose anyway, because the medication tray was cleaned this morning
- CDiscard the syringe and prepare the dose again with new equipment
- DBlow on the tip to remove any dust
5.Lab values & electrolytesMedium
The laboratory phones the ward with a critical potassium result of 6.9 mEq/L. What should the nurse do?
- AWait for the written report to arrive before taking any action at all
- BAsk the laboratory to repeat the test before telling anyone
- CRead back the value, assess the patient and inform the provider
- DRecord the value and hand it over to the next shift
6.Lab values & electrolytesHard
Which finding most strongly suggests that a patient’s raised creatinine is due to acute kidney injury rather than long-standing chronic kidney disease?
- AThe patient has long-standing anemia
- BThe patient has had a high creatinine for many years
- CThe patient has small kidneys on an ultrasound scan
- DThe creatinine was normal three days ago and has doubled since
7.Clinical nursingMedium
Why should a urinary catheter drainage bag be kept below the level of the bladder?
- ATo keep the urine warm
- BTo stop the catheter from falling out
- CTo make the bag easier for the nurse to empty
- DTo prevent urine flowing back into the bladder
8.Clinical nursingHard
A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?
- A"I will wear well-fitting shoes."
- B"I will see the podiatrist about hard skin."
- C"I will walk barefoot at home to toughen my feet."
- D"I will check my feet every day for cuts or blisters."
9.Med-surg: cardiovascular & respiratoryMedium
What is the ejection fraction?
- AThe percentage of ventricular blood ejected with each beat
- BThe pressure in the left ventricle at the end of diastolic filling
- CThe volume of blood pumped out with each heartbeat
- DThe volume of blood the heart pumps out every minute
10.Med-surg: cardiovascular & respiratoryHard
A patient with a confirmed calf DVT has started therapeutic anticoagulation and asks whether they must stay in bed. What is the most accurate answer?
- AWalking as tolerated is usually encouraged once treated
- BStrict bed rest is needed for at least two weeks
- CWalking is not allowed until the clot has fully dissolved
- DThe leg should be massaged before each walk
11.Med-surg: neuro, endocrine & renalMedium
Why is once-daily prednisolone usually taken in the morning with food?
- ATo match the natural cortisol rhythm and protect the stomach
- BBecause it cannot be absorbed at night
- CBecause it causes drowsiness and is safer to take during the day
- DBecause food doubles the strength of the dose
12.Med-surg: neuro, endocrine & renalHard
A patient with motor neurone disease reports morning headaches, poor sleep and sleepiness during the day. What do these symptoms suggest?
- ANormal tiredness that needs no specific action
- BWeak breathing at night, so a review for ventilation support
- CLow mood, which should be treated with an antidepressant first
- DA side effect of riluzole, which should be stopped straight away by the nurse
13.Med-surg: GI, perioperative & oncologyMedium
Which approach to red cell transfusion in a stable patient with a GI bleed fits current evidence?
- ANever transfuse, whatever the haemoglobin or the symptoms
- BA restrictive threshold, often around 70 g/L, in most stable patients
- CTransfuse everyone to keep the haemoglobin above 150 g/L at all times
- DTransfuse two units routinely before every endoscopy
14.Med-surg: GI, perioperative & oncologyHard
A worker has a hydrofluoric acid burn on the hand and severe pain. After irrigation with water, which specific treatment is commonly applied?
- ASilver sulfadiazine cream
- BSodium bicarbonate paste
- CIce cubes wrapped in a cloth
- DCalcium gluconate gel
3Solutions
1.Prioritization & delegation
Answer: D · Hold the next dose and report for an urgent lithium level
Why this is the answer
Vomiting, diarrhea and a coarse tremor suggest lithium toxicity. The nurse holds the dose and reports so a serum level can be checked; low salt or fluid intake raises lithium levels further.
D · Hold the next dose and report for an urgent lithium level
2.Prioritization & delegation
Answer: B · Talk to the assistant privately, restate what must be reported and follow up closely
Why this is the answer
The RN gives direct, private feedback, restates the reporting limits and increases supervision. If the problem continues, it is escalated to the manager according to policy.
B · Talk to the assistant privately, restate what must be reported and follow up closely
3.Infection control & patient safety
Answer: D · Decline, and give only medications that the nurse prepared or checked personally
Why this is the answer
Nurses give only medicines they prepared themselves or verified fully, because they are accountable for what they give. A drug prepared by someone else may be wrong in ways the nurse cannot see.
D · Decline, and give only medications that the nurse prepared or checked personally
4.Infection control & patient safety
Answer: C · Discard the syringe and prepare the dose again with new equipment
Why this is the answer
In aseptic non-touch technique, key parts such as syringe tips and IV hubs must not touch any non-sterile surface. A contaminated key part is not cleaned and reused. It is replaced.
C · Discard the syringe and prepare the dose again with new equipment
5.Lab values & electrolytes
Answer: C · Read back the value, assess the patient and inform the provider
Why this is the answer
Reading back a verbal result prevents errors. A critical value is reported to the provider without delay, and the nurse assesses the patient, including heart rhythm. A repeat sample may be needed, but it must not delay the response.
C · Read back the value, assess the patient and inform the provider
6.Lab values & electrolytes
Answer: D · The creatinine was normal three days ago and has doubled since
Why this is the answer
A rapid rise from a normal baseline over days is the hallmark of acute kidney injury. Long-standing raised values, small kidneys and chronic anemia point to chronic kidney disease.Checked against: Acute Kidney Injury · StatPearls (NCBI Bookshelf) (2026)
D · The creatinine was normal three days ago and has doubled since
7.Clinical nursing
Answer: D · To prevent urine flowing back into the bladder
Why this is the answer
Keeping the bag below the bladder allows drainage and prevents backflow, which reduces infection risk. The bag should also not touch the floor.
D · To prevent urine flowing back into the bladder
8.Clinical nursing
Answer: C · "I will walk barefoot at home to toughen my feet."
Why this is the answer
Diabetic neuropathy and poor circulation mean small injuries can become ulcers. Patients should avoid walking barefoot, inspect their feet daily and get professional foot care.
C · "I will walk barefoot at home to toughen my feet."
9.Med-surg: cardiovascular & respiratory
Answer: A · The percentage of ventricular blood ejected with each beat
Why this is the answer
Ejection fraction = stroke volume ÷ end-diastolic volume, normally about 50–70%. Heart failure with reduced ejection fraction is usually defined as 40% or less. Cardiac output is the volume per minute and stroke volume the volume per beat.
A · The percentage of ventricular blood ejected with each beat
10.Med-surg: cardiovascular & respiratory
Answer: A · Walking as tolerated is usually encouraged once treated
Why this is the answer
Early mobilisation with effective anticoagulation does not increase the risk of pulmonary embolism and may reduce pain, swelling and post-thrombotic syndrome. Routine bed rest is no longer recommended. Massage of the affected leg should be avoided.
A · Walking as tolerated is usually encouraged once treated
11.Med-surg: neuro, endocrine & renal
Answer: A · To match the natural cortisol rhythm and protect the stomach
Why this is the answer
Morning dosing mimics the normal early-morning cortisol peak, causes less adrenal suppression and less sleep disturbance. Taking it with food reduces gastric irritation.
A · To match the natural cortisol rhythm and protect the stomach
12.Med-surg: neuro, endocrine & renal
Answer: B · Weak breathing at night, so a review for ventilation support
Why this is the answer
Weak respiratory muscles cause nocturnal hypoventilation and a rise in CO2, leading to morning headaches, disturbed sleep and daytime drowsiness. Non-invasive ventilation can improve symptoms and survival, in line with the patient's wishes.
B · Weak breathing at night, so a review for ventilation support
13.Med-surg: GI, perioperative & oncology
Answer: B · A restrictive threshold, often around 70 g/L, in most stable patients
Why this is the answer
Restrictive transfusion (often at a haemoglobin of about 70 g/L, with a target of 70–90 g/L, or a higher threshold in cardiovascular disease) is associated with better outcomes in many GI bleeding patients than liberal transfusion. Massive haemorrhage is managed by major haemorrhage protocols.
B · A restrictive threshold, often around 70 g/L, in most stable patients
14.Med-surg: GI, perioperative & oncology
Answer: D · Calcium gluconate gel
Why this is the answer
Hydrofluoric acid penetrates deeply and binds calcium and magnesium, causing severe pain and possible life-threatening hypocalcaemia. Calcium gluconate gel binds fluoride; serum calcium and heart rhythm are monitored in larger exposures.
D · Calcium gluconate gel
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