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 instruction to a nursing assistant is the clearest?
- A“Measure Mr Lee’s blood pressure at 10:00 and tell me at once if the systolic is below 100.”
- B“Keep an eye on Mr Lee this morning and let me know how he is doing.”
- C“Let me know if anything seems wrong with Mr Lee while you are in there.”
- D“Do Mr Lee’s vital signs sometime before lunch and write them on the chart for me.”
2.Prioritization & delegationHard
A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?
- AHow to cook low-fat meals
- BHow to choose comfortable walking shoes
- CWhich television programs help with relaxation
- DSigns of bleeding and when to seek help
3.Infection control & patient safetyMedium
Why is keeping a patient warm (normothermia) during surgery part of infection prevention?
- ALow body temperature reduces blood flow and immune function in the wound
- BWarm patients do not need antibiotic prophylaxis
- CCold makes bacteria grow faster in the operating room air and on the drapes
- DWarmth sterilizes the surgical site
4.Infection control & patient safetyHard
A patient with a sealed radioactive implant reports that the implant has fallen out onto the bed. What should the nurse do?
- ALeave it on the bed until the radiation team arrives tomorrow
- BAsk the patient to hold it until help arrives
- CPick it up with gloved hands and put it in the clinical waste
- DUse long-handled forceps to place it in the lead container
5.Lab values & electrolytesMedium
A tired patient with heavy menstrual periods has a normal hemoglobin and MCV but a ferritin of 8 ng/mL. What does this show?
- AIron overload from too much iron
- BVitamin B12 deficiency anemia
- CA completely normal iron status
- DIron deficiency without anemia yet
6.Lab values & electrolytesHard
Why can a normal creatinine be misleading in a frail older adult with low muscle mass?
- AA normal creatinine always proves normal kidney function
- BCreatinine levels do not depend on muscle mass at all
- COlder adults always have a higher creatinine than younger adults do
- DLess muscle makes less creatinine, hiding reduced kidney function
7.Clinical nursingMedium
A rising serum creatinine most often indicates:
- ADehydration of the skin only
- BReduced kidney function
- CIncreased muscle strength
- DImproved liver function
8.Clinical nursingHard
Which feature suggests moisture-associated skin damage rather than a pressure ulcer?
- AA round area of necrosis over the heel
- BNon-blanching redness directly over the hip bone after lying on one side
- CDiffuse, superficial redness in a skin fold, not over a bony prominence
- DA deep wound over the sacrum with exposed bone and a dark base
9.Med-surg: cardiovascular & respiratoryMedium
A patient's capillary refill time at the fingertip is 4 seconds. What does this suggest?
- ANormal peripheral perfusion
- BReduced peripheral perfusion
- CA high haemoglobin level
- DAn unusually strong cardiac output
10.Med-surg: cardiovascular & respiratoryHard
Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?
- AA patient who had a brain haemorrhage two days ago
- BAn obese patient after hip surgery
- CA patient after an uncomplicated knee replacement
- DA patient with cancer having bowel surgery
11.Med-surg: neuro, endocrine & renalMedium
A patient on peritoneal dialysis has gained weight and has higher glucose levels. Which part of the treatment is the likely cause?
- AProtein lost into the dialysis fluid
- BSodium lost into the dialysis fluid
- CGlucose absorbed from the dialysis fluid
- DAir entering the abdomen during exchanges
12.Med-surg: neuro, endocrine & renalHard
A patient with acute ischaemic stroke is not a thrombolysis candidate. On day 1 the BP is 190/100 mmHg with no other emergency. What is generally appropriate?
- ALie the patient flat and give a large fluid bolus
- BAvoid aggressive lowering and follow the stroke team's targets
- CGive nitrate spray every 5 minutes until below 120 mmHg
- DLower it rapidly to 110/70 mmHg with IV drugs
13.Med-surg: GI, perioperative & oncologyMedium
Which pain pattern classically suggests a duodenal rather than a gastric ulcer?
- APain only on deep breathing that eases when sitting forwards
- BPain straight after eating that is worsened by food
- CPain in the right lower abdomen with fever and vomiting
- DPain 2–3 hours after meals and at night, eased by eating
14.Med-surg: GI, perioperative & oncologyHard
An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?
- AAn arterial ulcer caused by poor circulation
- BA full-thickness burn
- CA category 4 pressure ulcer over the sacrum
- DIncontinence-associated dermatitis
3Solutions
1.Prioritization & delegation
Answer: A · “Measure Mr Lee’s blood pressure at 10:00 and tell me at once if the systolic is below 100.”
Why this is the answer
The best instruction says exactly what to do, when, and which values must be reported at once. The other instructions leave the assistant to guess what matters.
A · “Measure Mr Lee’s blood pressure at 10:00 and tell me at once if the systolic is below 100.”
2.Prioritization & delegation
Answer: D · Signs of bleeding and when to seek help
Why this is the answer
The main risk of anticoagulants is bleeding, so the patient must know the signs, such as black stools or blood in the urine, and when to seek help. Other topics can follow later.
D · Signs of bleeding and when to seek help
3.Infection control & patient safety
Answer: A · Low body temperature reduces blood flow and immune function in the wound
Why this is the answer
Hypothermia causes vasoconstriction and less oxygen in the wound, which weakens the immune defense. Keeping the patient warm is linked to fewer surgical site infections.
A · Low body temperature reduces blood flow and immune function in the wound
4.Infection control & patient safety
Answer: D · Use long-handled forceps to place it in the lead container
Why this is the answer
A dislodged source is never touched by hand. Long-handled forceps keep distance, the lead container shields the source, and the radiation safety officer is informed immediately.
D · Use long-handled forceps to place it in the lead container
5.Lab values & electrolytes
Answer: D · Iron deficiency without anemia yet
Why this is the answer
Iron stores (ferritin) are depleted before the hemoglobin falls. A low ferritin with a normal hemoglobin indicates iron deficiency without anemia, and it is usually treated, along with the cause of blood loss.Checked against: Ferritin Blood Test · MedlinePlus (NIH) (2025); Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025)
D · Iron deficiency without anemia yet
6.Lab values & electrolytes
Answer: D · Less muscle makes less creatinine, hiding reduced kidney function
Why this is the answer
Creatinine is made by muscle. A person with little muscle makes little creatinine, so the value can look normal even when kidney function is reduced. Creatinine-based eGFR can overestimate function in the same way, so a measured creatinine clearance or a cystatin C–based estimate may be used when dosing drugs cleared by the kidneys.Checked against: Creatinine blood test · MedlinePlus (NIH) (2025)
D · Less muscle makes less creatinine, hiding reduced kidney function
7.Clinical nursing
Answer: B · Reduced kidney function
Why this is the answer
Creatinine is a muscle waste product filtered by the kidneys. A rise shows the glomerular filtration rate is falling, as in acute kidney injury.
B · Reduced kidney function
8.Clinical nursing
Answer: C · Diffuse, superficial redness in a skin fold, not over a bony prominence
Why this is the answer
Moisture lesions are superficial, irregular and often in skin folds or areas exposed to incontinence. Pressure ulcers usually occur over bony prominences or under devices and may be deeper.
C · Diffuse, superficial redness in a skin fold, not over a bony prominence
9.Med-surg: cardiovascular & respiratory
Answer: B · Reduced peripheral perfusion
Why this is the answer
Capillary refill time above about 2 seconds suggests poor peripheral perfusion, for example from dehydration, shock or cold. It should be interpreted with other signs such as heart rate, blood pressure, skin temperature and urine output.
B · Reduced peripheral perfusion
10.Med-surg: cardiovascular & respiratory
Answer: A · A patient who had a brain haemorrhage two days ago
Why this is the answer
When bleeding risk is high, such as after recent intracranial haemorrhage, mechanical methods (intermittent pneumatic compression) are used instead of anticoagulants until it is safe. The other patients are at high VTE risk and would usually receive pharmacological prophylaxis unless contraindicated.
A · A patient who had a brain haemorrhage two days ago
11.Med-surg: neuro, endocrine & renal
Answer: C · Glucose absorbed from the dialysis fluid
Why this is the answer
Standard PD fluids contain glucose to pull water out by osmosis. Some glucose is absorbed, adding calories and raising blood glucose. Glucose monitoring and diet advice are needed, and other solutions may be used.
C · Glucose absorbed from the dialysis fluid
12.Med-surg: neuro, endocrine & renal
Answer: B · Avoid aggressive lowering and follow the stroke team's targets
Why this is the answer
After ischaemic stroke, the penumbra depends on blood pressure for perfusion. Unless thrombolysis is planned or there is another emergency (such as aortic dissection or acute heart failure), guidelines often accept higher pressures early (for example treating only above 220/120 mmHg in some guidance). Targets are set by the stroke team.
B · Avoid aggressive lowering and follow the stroke team's targets
13.Med-surg: GI, perioperative & oncology
Answer: D · Pain 2–3 hours after meals and at night, eased by eating
Why this is the answer
Classically, duodenal ulcer pain occurs when the stomach is empty and at night, and food or antacids ease it. Gastric ulcer pain is often brought on by eating. Patterns overlap, so endoscopy makes the diagnosis.
D · Pain 2–3 hours after meals and at night, eased by eating
14.Med-surg: GI, perioperative & oncology
Answer: D · Incontinence-associated dermatitis
Why this is the answer
Incontinence-associated dermatitis is inflammation from urine or faeces, with diffuse redness and superficial erosion. It is managed with gentle cleansing, barrier products and managing incontinence, and is different from a pressure ulcer.
D · Incontinence-associated dermatitis
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