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
Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?
- AIron deficiency anemia
- BVitamin K deficiency
- CAn expected effect that needs no action
- DHeparin-induced thrombocytopenia
2.Prioritization & delegationHard
A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?
- A“I will inject into the fat of my abdomen, away from the navel.”
- B“I will tell my doctor if I notice unusual bruising or bleeding.”
- C“I will change the injection site each time.”
- D“I will rub the area after the injection to help it absorb.”
3.Infection control & patient safetyMedium
When should the transparent dressing over a peripheral IV site be changed?
- AWhen it is damp, loose or visibly soiled
- BOnly when the patient asks for a new dressing
- COnly when the IV catheter is removed, whatever its state
- DEvery hour, so the site can be cleaned again
4.Infection control & patient safetyHard
A patient on airborne precautions for tuberculosis wants to walk in the hallway. What is the best response?
- AExplain that they must stay in the room, and offer ways to stay active inside it
- BAllow it, as long as the patient wears an N95 respirator in the corridor
- CAllow it, if they avoid the nurses’ station
- DAllow it, as long as they walk quickly
5.Lab values & electrolytesMedium
Why must vitamin B12 deficiency be ruled out before treating macrocytic anemia with folic acid alone?
- AFolic acid blocks the absorption of all B12 from the diet
- BFolic acid makes B12 deficiency anemia much worse within a few days
- CFolic acid can fix the anemia while B12-related nerve damage continues
- DFolic acid causes iron overload when B12 levels are low
6.Lab values & electrolytesHard
A patient's total calcium is 7.6 mg/dL and the albumin is 2.0 g/dL. Using the common correction (add 0.8 mg/dL for each 1 g/dL that albumin is below 4.0), what is the corrected calcium?
- A9.2 mg/dL, within the normal range
- B6.0 mg/dL, well below the normal range
- C7.6 mg/dL, below the normal range
- D11.6 mg/dL, above the normal range
7.Clinical nursingMedium
A patient has a continuous stream of bubbles in the water seal chamber of their chest drain. What does this most likely indicate?
- AAn air leak, from the lung or from the drainage system
- BThe drain is blocked
- CThe drain is working normally for a fluid collection only
- DThe lung has fully re-expanded
8.Clinical nursingHard
A nurse is unsure whether a prescribed dose of a high-risk drug is correct. What is the safest action?
- AGive half the dose as a compromise until the doctor is available
- BGive the dose because the doctor has signed the prescription
- CAsk the patient whether the dose looks the same as usual and give it
- DWithhold it and check with the prescriber or pharmacist first
9.Med-surg: cardiovascular & respiratoryMedium
A patient with heart failure asks why salt is being limited. Which explanation is correct?
- ASodium directly weakens the contracting heart muscle
- BSodium stops the diuretic tablets from being absorbed properly
- CSodium makes the body retain water, which adds to congestion
- DSodium raises the heart rate during sleep
10.Med-surg: cardiovascular & respiratoryHard
A frightened young woman is breathing fast and has tingling fingers. Her blood gas shows pH 7.50 and a low PaCO₂. SpO₂ is 99% on air. What does this show?
- AMetabolic acidosis from kidney failure
- BMetabolic alkalosis from vomiting
- CRespiratory alkalosis from hyperventilation
- DRespiratory acidosis from hypoventilation
11.Med-surg: neuro, endocrine & renalMedium
Which statement about hyperosmolar hyperglycaemic state (HHS) is correct?
- AIt is seen mainly in young children with type 1 diabetes
- BIt develops within minutes and is less dangerous than DKA
- CIt always causes high blood ketones and a severe metabolic acidosis
- DIt mainly affects older people with type 2 diabetes, over days
12.Med-surg: neuro, endocrine & renalHard
A patient with CKD has a haemoglobin of 92 g/L and starts an erythropoiesis-stimulating agent (ESA). What should the nurse monitor?
- ABlood pressure and haemoglobin, as overshoot raises clot risk
- BBlood glucose, because ESAs often cause hypoglycaemia
- CLiver enzymes, because ESAs are toxic to the liver
- DHearing, because ESAs can damage the inner ear
13.Med-surg: GI, perioperative & oncologyMedium
A patient with an ileal conduit (urostomy) is worried about mucus in the urine. What is the correct explanation?
- AIt is normal, as the conduit is made from small bowel
- BIt is a sign of a kidney stone and must be reported today
- CIt means the stoma is failing and needs surgery
- DIt shows a bowel obstruction is developing
14.Med-surg: GI, perioperative & oncologyHard
Using the adult rule of nines, what is the total burn area of the whole right arm plus the whole front of the trunk (both with partial-thickness burns)?
- A45%
- B18%
- C36%
- D27%
3Solutions
1.Prioritization & delegation
Answer: D · Heparin-induced thrombocytopenia
Why this is the answer
Heparin-induced thrombocytopenia usually appears 5–10 days after starting heparin, with a large fall in platelets and a risk of clotting. The nurse reports at once so heparin can be stopped.
D · Heparin-induced thrombocytopenia
2.Prioritization & delegation
Answer: D · “I will rub the area after the injection to help it absorb.”
Why this is the answer
Rubbing the site after a low-molecular-weight heparin injection increases bruising. The abdomen away from the navel, rotating sites and reporting bleeding are correct.
D · “I will rub the area after the injection to help it absorb.”
3.Infection control & patient safety
Answer: A · When it is damp, loose or visibly soiled
Why this is the answer
A dressing that is wet, loose or dirty no longer protects the insertion site and is changed using aseptic technique. Otherwise, it is changed according to policy.
A · When it is damp, loose or visibly soiled
4.Infection control & patient safety
Answer: A · Explain that they must stay in the room, and offer ways to stay active inside it
Why this is the answer
Patients on airborne precautions stay in the negative-pressure room with the door closed, leaving only for essential tests while wearing a surgical mask. The nurse explains why and helps the patient cope with confinement.
A · Explain that they must stay in the room, and offer ways to stay active inside it
5.Lab values & electrolytes
Answer: C · Folic acid can fix the anemia while B12-related nerve damage continues
Why this is the answer
Folic acid can improve the blood picture in B12 deficiency but does not prevent nerve damage. Giving folate alone can therefore mask the deficiency while neurological damage progresses. Both levels are checked before treatment.
C · Folic acid can fix the anemia while B12-related nerve damage continues
6.Lab values & electrolytes
Answer: A · 9.2 mg/dL, within the normal range
Why this is the answer
Corrected calcium = 7.6 + 0.8 × (4.0 − 2.0) = 9.2 mg/dL, which is normal. Low albumin lowers the bound fraction of calcium; the correction is only an estimate, and an ionized calcium is more accurate when it matters.Checked against: Calcium blood test · MedlinePlus (NIH) (2025)
A · 9.2 mg/dL, within the normal range
7.Clinical nursing
Answer: A · An air leak, from the lung or from the drainage system
Why this is the answer
Bubbling with breathing in a drain for pneumothorax shows air is leaving the pleural space. Continuous bubbling can also mean a leak in the connections, so the system is checked and the finding reported.
A · An air leak, from the lung or from the drainage system
8.Clinical nursing
Answer: D · Withhold it and check with the prescriber or pharmacist first
Why this is the answer
Nurses must understand any drug they administer. If a dose seems wrong, they should check with the prescriber or pharmacist and document the action.
D · Withhold it and check with the prescriber or pharmacist first
9.Med-surg: cardiovascular & respiratory
Answer: C · Sodium makes the body retain water, which adds to congestion
Why this is the answer
Sodium retention leads to water retention, increasing circulating volume, preload and congestion. Limiting sodium and, in some patients, fluid helps control oedema and breathlessness. The exact limits are set by the prescriber.
C · Sodium makes the body retain water, which adds to congestion
10.Med-surg: cardiovascular & respiratory
Answer: C · Respiratory alkalosis from hyperventilation
Why this is the answer
Hyperventilation blows off CO₂, causing respiratory alkalosis. The alkalosis lowers ionised calcium, causing tingling and carpopedal spasm. Normal oxygen saturation is reassuring, but organic causes such as PE, asthma or diabetic ketoacidosis must still be excluded.
C · Respiratory alkalosis from hyperventilation
11.Med-surg: neuro, endocrine & renal
Answer: D · It mainly affects older people with type 2 diabetes, over days
Why this is the answer
HHS develops over days, often triggered by infection, with extreme hyperglycaemia, very high osmolality and profound dehydration, frequently with confusion. Enough insulin is present to prevent marked ketosis. Mortality is higher than in DKA, and there is a high risk of thrombosis.
D · It mainly affects older people with type 2 diabetes, over days
12.Med-surg: neuro, endocrine & renal
Answer: A · Blood pressure and haemoglobin, as overshoot raises clot risk
Why this is the answer
ESAs can cause hypertension and, when haemoglobin is pushed too high, increase the risk of thrombosis and stroke. Haemoglobin is targeted to a moderate range (commonly about 100–120 g/L). Iron stores are checked because iron deficiency limits the response.
A · Blood pressure and haemoglobin, as overshoot raises clot risk
13.Med-surg: GI, perioperative & oncology
Answer: A · It is normal, as the conduit is made from small bowel
Why this is the answer
An ileal conduit uses a segment of ileum, which continues to produce mucus. Patients are encouraged to drink well to keep the urine flowing. Cloudy, offensive urine with fever, however, suggests infection.
A · It is normal, as the conduit is made from small bowel
14.Med-surg: GI, perioperative & oncology
Answer: D · 27%
Why this is the answer
The whole arm is 9% and the front of the trunk 18%, giving 27% total body surface area. Superficial (redness only) areas would not be counted.
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