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 nurse teaches a patient about levothyroxine. Which statement shows a need for further teaching?
- A“I will take it at breakfast with my calcium tablet.”
- B“I will take it at the same time each morning.”
- C“I will take it on an empty stomach with a glass of water.”
- D“I will keep taking it even when I feel well.”
2.Prioritization & delegationHard
A charge nurse notices that a nurse smells of alcohol and is slurring words at the start of the shift. What is the priority?
- AWait until the end of the shift and then discuss the concern with the nurse privately
- BAsk the nurse to drink coffee and then start work
- CRemove the nurse from patient care and report it according to policy
- DLet the nurse work, but only with stable patients
3.Infection control & patient safetyMedium
A patient wishes to refuse a prescribed medicine. What should the nurse do?
- AHide the medicine in the patient’s food or drink to make sure it is taken
- BRecord the dose as given to avoid questions from the team
- CExplore the reason, explain, respect a competent choice and document
- DGive it anyway, because it was prescribed
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?
- AGive the dose anyway, because the medication tray was cleaned this morning
- BDiscard the syringe and prepare the dose again with new equipment
- CWipe the tip with an alcohol swab and give the dose
- DBlow on the tip to remove any dust
5.Lab values & electrolytesMedium
A patient on warfarin started eating large daily portions of kale and spinach. The INR has fallen. What advice is most appropriate?
- AKeep the intake of vitamin K–rich foods steady from day to day
- BNever eat green vegetables again
- CDouble the warfarin dose without telling the prescriber
- DStop warfarin until the diet is normal
6.Lab values & electrolytesHard
The nurse prepares a patient for a 2-hour oral glucose tolerance test tomorrow morning. Which statement shows a need for further teaching?
- A"I'll avoid smoking until the test is over"
- B"I can have a light breakfast before the test"
- C"I'll fast overnight but can drink plain water"
- D"I'll stay seated during the test if I can"
7.Clinical nursingMedium
Which advice is correct for a patient taking levothyroxine?
- ATake it with a large meal to avoid nausea and stomach upset
- BStop taking it once the symptoms improve
- CTake it only on days when feeling tired
- DTake it on an empty stomach, usually before breakfast
8.Clinical nursingHard
A patient with acute pancreatitis is in severe epigastric pain radiating to the back. Which nursing care is most important?
- AAdequate pain relief, IV fluids and close fluid balance monitoring
- BRestricting all fluids
- CStrict bed rest without observations
- DA large fatty meal to stimulate the pancreas
9.Med-surg: cardiovascular & respiratoryMedium
A patient on home oxygen has dry, sore lips. Which product is safest to use?
- AA water-based lubricant
- BPetroleum jelly
- CAn oil-based balm
- DAn alcohol-based gel
10.Med-surg: cardiovascular & respiratoryHard
A patient with asthma needs their reliever every three hours and their peak flow is falling well below their personal best. What does their action plan most likely advise?
- AStop the preventer inhaler for a few days to rest the lungs
- BFollow the worsening-asthma steps and get a same-day review
- CWait two weeks to see whether it improves without any change
- DDo extra exercise to open the airways
11.Med-surg: neuro, endocrine & renalMedium
A patient with gout has recurrent uric acid kidney stones. Which treatment helps prevent them?
- AAllopurinol and making the urine less acidic
- BCalcium tablets and a low-fluid diet
- CRestricting fluids in the evening only
- DVitamin C supplements and a high-meat diet
12.Med-surg: neuro, endocrine & renalHard
A patient taking an SGLT2 inhibitor is booked for major surgery. Which statement is correct?
- AThe dose is usually doubled on the morning of surgery
- BSurgery is not possible in patients taking this drug
- CThe drug must be taken right up until the operation starts
- DIt is usually paused in the days before surgery
13.Med-surg: GI, perioperative & oncologyMedium
Which area is used as a quick estimate of 1% of body surface area for small or scattered burns?
- AThe patient's palm including the fingers
- BThe patient's hand and forearm
- CThe examiner's palm including the fingers
- DThe patient's thumbnail
14.Med-surg: GI, perioperative & oncologyHard
After a high-voltage electrical injury, a patient's urine is dark red-brown. What does this suggest and what is the usual aim?
- ABleeding from the bladder; stop all fluids
- BMyoglobin from muscle damage; a higher urine output target
- CNormal concentrated urine; restrict fluids
- DA urinary infection; send a sample and wait for the result
3Solutions
1.Prioritization & delegation
Answer: A · “I will take it at breakfast with my calcium tablet.”
Why this is the answer
Levothyroxine is best absorbed on an empty stomach and is separated from calcium and iron by several hours. It is usually lifelong, so it is not stopped when the patient feels better.
A · “I will take it at breakfast with my calcium tablet.”
2.Prioritization & delegation
Answer: C · Remove the nurse from patient care and report it according to policy
Why this is the answer
A nurse who appears impaired must not care for patients. The charge nurse removes them from duty and follows policy for reporting; support, such as an assistance program, can follow.
C · Remove the nurse from patient care and report it according to policy
3.Infection control & patient safety
Answer: C · Explore the reason, explain, respect a competent choice and document
Why this is the answer
The right to refuse is one of the rights of medication administration. The nurse finds out why and gives information, but a competent patient’s decision is respected. Covert administration without a legal process, or false documentation, is unacceptable.
C · Explore the reason, explain, respect a competent choice and document
4.Infection control & patient safety
Answer: B · 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.
B · Discard the syringe and prepare the dose again with new equipment
5.Lab values & electrolytes
Answer: A · Keep the intake of vitamin K–rich foods steady from day to day
Why this is the answer
Vitamin K counteracts warfarin, so a large increase in leafy greens lowers the INR. Patients do not have to avoid these foods, but they should keep the amount consistent so the dose can be set correctly.Checked against: Warfarin · MedlinePlus (NIH) (2026); Taking warfarin · MedlinePlus (NIH) (2025)
A · Keep the intake of vitamin K–rich foods steady from day to day
6.Lab values & electrolytes
Answer: B · "I can have a light breakfast before the test"
Why this is the answer
The OGTT is done after an overnight fast of at least 8 hours; water is allowed. Eating before the test makes the results invalid. Patients rest during the test and avoid smoking, which can affect glucose.Checked against: Blood Glucose Test · MedlinePlus (NIH) (2024); Glucose tolerance test - non-pregnant · MedlinePlus (NIH) (2025)
B · "I can have a light breakfast before the test"
7.Clinical nursing
Answer: D · Take it on an empty stomach, usually before breakfast
Why this is the answer
Levothyroxine is absorbed best on an empty stomach and is usually taken at the same time each morning. It is normally lifelong, with doses adjusted by thyroid blood tests.
D · Take it on an empty stomach, usually before breakfast
8.Clinical nursing
Answer: A · Adequate pain relief, IV fluids and close fluid balance monitoring
Why this is the answer
Acute pancreatitis can cause large fluid losses and organ failure. Care focuses on fluid resuscitation, analgesia, monitoring urine output, glucose and early nutrition when possible.
A · Adequate pain relief, IV fluids and close fluid balance monitoring
9.Med-surg: cardiovascular & respiratory
Answer: A · A water-based lubricant
Why this is the answer
Oil-based products such as petroleum jelly can ignite or burn intensely in high oxygen concentrations and have caused facial burns. Water-based products are recommended. Oxygen cylinders are kept upright and secured, away from heat and flames.
A · A water-based lubricant
10.Med-surg: cardiovascular & respiratory
Answer: B · Follow the worsening-asthma steps and get a same-day review
Why this is the answer
Personal asthma action plans set steps based on symptoms and peak flow compared with the personal best. Increasing reliever need and a falling peak flow mean worsening asthma: treatment is increased as the plan says (sometimes with oral steroids) and urgent review is sought. Severe signs need emergency care.
B · Follow the worsening-asthma steps and get a same-day review
11.Med-surg: neuro, endocrine & renal
Answer: A · Allopurinol and making the urine less acidic
Why this is the answer
Uric acid stones form when urine is acidic and rich in uric acid. High fluid intake, alkalinising the urine (for example with potassium citrate) and allopurinol reduce the risk. Purine-rich foods are limited.
A · Allopurinol and making the urine less acidic
12.Med-surg: neuro, endocrine & renal
Answer: D · It is usually paused in the days before surgery
Why this is the answer
Fasting, surgery and dehydration increase the risk of euglycaemic DKA with SGLT2 inhibitors. Guidance usually advises stopping them in the days before major surgery and restarting when the patient is eating and drinking normally.
D · It is usually paused in the days before surgery
13.Med-surg: GI, perioperative & oncology
Answer: A · The patient's palm including the fingers
Why this is the answer
The patient's palm with the fingers together is about 1% of their total body surface area. It is useful for small or patchy burns. Simple erythema (superficial burns) is not included in the total.
A · The patient's palm including the fingers
14.Med-surg: GI, perioperative & oncology
Answer: B · Myoglobin from muscle damage; a higher urine output target
Why this is the answer
Electrical injury can cause extensive muscle breakdown, releasing myoglobin that can damage the kidneys. A higher urine output target is set, with fluids titrated and creatine kinase and kidney function monitored.
B · Myoglobin from muscle damage; a higher urine output target
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