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 two patients can most safely share a room?
- AA patient with chickenpox and a patient on chemotherapy
- BA patient with MRSA in a wound and a patient after surgery
- CTwo patients who both have C. difficile infection
- DA patient with influenza and a patient with COPD
2.Prioritization & delegationHard
Which patient on a renal unit should the nurse see first?
- AA patient on peritoneal dialysis whose drained fluid is clear
- BA patient whose arteriovenous fistula has a strong thrill and bruit
- CA patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
- DA patient asking for advice about a low-phosphate diet
3.Infection control & patient safetyMedium
A nurse’s hands are dry and cracked from frequent hand hygiene. What is the best approach?
- AWear gloves all day instead of cleaning the hands between patients
- BUse the hand lotion approved by the facility to keep the skin intact
- CUse any lotion from home, whatever its contents
- DStop hand hygiene until the skin heals
4.Infection control & patient safetyHard
Which patient with a suspected infection meets at least two SIRS criteria?
- ATemperature 38.6 °C and heart rate 112/min
- BTemperature 36.8 °C and respiratory rate 18/min
- CTemperature 37.2 °C and heart rate 80/min
- DRespiratory rate 16/min and WBC 8,000/mm3
5.Lab values & electrolytesMedium
A patient on warfarin for atrial fibrillation has an INR of 1.4. What does this mean?
- AThe dose is exactly right and needs no change
- BThe patient is at a high risk of bleeding and needs vitamin K at once
- CThe patient no longer needs to take warfarin
- DAnticoagulation is below target, so clots and stroke are more likely
6.Lab values & electrolytesHard
A patient has marked generalized edema. Results show heavy proteinuria, serum albumin 1.8 g/dL (18 g/L) and total cholesterol 340 mg/dL (8.8 mmol/L). Which condition fits best?
- APrerenal kidney injury
- BLiver cirrhosis only
- CAcute pyelonephritis
- DNephrotic syndrome
7.Clinical nursingMedium
Which measure helps prevent delirium in older inpatients?
- AMoving the patient to a different bed each night to give them a change of scene
- BRestricting fluids to avoid incontinence
- CKeeping the lights on all night
- DReorientation, glasses and hearing aids in use, and good sleep and hydration
8.Clinical nursingHard
A patient has a blood pressure of 220/130 mmHg with headache, confusion and visual disturbance. Why is the blood pressure lowered in a controlled way rather than as fast as possible?
- AA sudden drop can reduce blood flow to the brain, heart and kidneys
- BRapid lowering causes hyperglycaemia
- CRapid lowering always causes the hypertension to come back much worse
- DBlood pressure cannot be lowered with drugs
9.Med-surg: cardiovascular & respiratoryMedium
A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?
- AA theophylline allergy causing a rash
- BAn expected sign that the drug is working
- CTheophylline toxicity
- DHypoglycaemia caused by the drug
10.Med-surg: cardiovascular & respiratoryHard
An older patient with three rib fractures is breathing shallowly and refuses to cough because of pain. What is the priority intervention?
- AKeep the patient flat and still in bed until the pain settles
- BEffective analgesia so they can breathe deeply and cough
- CStrap the chest tightly with bandages to stop the ribs moving
- DWithhold analgesia to avoid depressing breathing
11.Med-surg: neuro, endocrine & renalMedium
A patient with multiple sclerosis says their symptoms get worse after a hot bath. What should the nurse explain?
- AThis shows that the disease has entered a new progressive stage
- BHeat can briefly worsen MS symptoms, which settle when they cool down
- CHot baths cause new areas of damage in the brain
- DThey should take very cold baths to reverse the damage
12.Med-surg: neuro, endocrine & renalHard
A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?
- AKidney disease makes the body resistant to insulin
- BThe kidneys clear less insulin, so it lasts longer
- CKidney disease makes the meter read too low
- DThe patient is eating far more carbohydrate than before
13.Med-surg: GI, perioperative & oncologyMedium
Why does a patient need lifelong vitamin B12 injections after total gastrectomy?
- AThe small bowel stops absorbing all nutrients
- BThe liver can no longer store any vitamins
- CVitamin B12 is lost in the urine after the surgery
- DIntrinsic factor from the stomach is no longer made
14.Med-surg: GI, perioperative & oncologyHard
A patient on a long-term opioid for chronic pain is admitted for surgery. Which statement is correct?
- AThe usual opioid is continued, plus extra analgesia, due to tolerance
- BAll opioids should be stopped on admission to prevent addiction
- CThey should receive only paracetamol after the operation is over
- DThey need lower postoperative opioid doses than opioid-naive patients
3Solutions
1.Prioritization & delegation
Answer: C · Two patients who both have C. difficile infection
Why this is the answer
Cohorting patients with the same organism is acceptable when single rooms are not available. The other pairs would expose a vulnerable patient to an infection.
C · Two patients who both have C. difficile infection
2.Prioritization & delegation
Answer: C · A patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
Why this is the answer
A missed dialysis session lets potassium build up. Muscle weakness and an irregular pulse suggest hyperkalemia, which can cause fatal arrhythmias, so the nurse assesses at once, arranges cardiac monitoring and escalates. A thrill and bruit and clear effluent are expected findings, and diet advice can wait.
C · A patient on hemodialysis who missed yesterday’s session and now has muscle weakness and an irregular pulse
3.Infection control & patient safety
Answer: B · Use the hand lotion approved by the facility to keep the skin intact
Why this is the answer
Cracked skin is harder to clean and harbors more organisms. Facility-approved lotions help keep the skin healthy without reducing the effect of hand antiseptics such as chlorhexidine.
B · Use the hand lotion approved by the facility to keep the skin intact
4.Infection control & patient safety
Answer: A · Temperature 38.6 °C and heart rate 112/min
Why this is the answer
SIRS criteria include a temperature above 38 °C or below 36 °C, heart rate above 90/min, respiratory rate above 20/min and a WBC above 12,000 or below 4,000/mm3. Only the first patient meets two.
A · Temperature 38.6 °C and heart rate 112/min
5.Lab values & electrolytes
Answer: D · Anticoagulation is below target, so clots and stroke are more likely
Why this is the answer
An INR below the target range means the blood clots too readily for this indication. The prescriber is informed, and the dose and possible causes, such as missed doses or interactions, are reviewed.Checked against: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024)
D · Anticoagulation is below target, so clots and stroke are more likely
6.Lab values & electrolytes
Answer: D · Nephrotic syndrome
Why this is the answer
Nephrotic syndrome is heavy proteinuria with low albumin, edema and high lipids. Low albumin reduces oncotic pressure, causing edema, and the liver increases lipoprotein production. There is also a higher risk of clots and infection.Checked against: Nephrotic syndrome · MedlinePlus (NIH) (2025)
7.Clinical nursing
Answer: D · Reorientation, glasses and hearing aids in use, and good sleep and hydration
Why this is the answer
Multicomponent prevention, including orientation, sensory aids, hydration, nutrition, mobility, sleep and avoiding unnecessary moves or drugs, reduces delirium.
D · Reorientation, glasses and hearing aids in use, and good sleep and hydration
8.Clinical nursing
Answer: A · A sudden drop can reduce blood flow to the brain, heart and kidneys
Why this is the answer
In a hypertensive emergency, autoregulation in vital organs is reset to higher pressures. Lowering BP too fast can cause ischaemia, so it is reduced gradually under close monitoring.
A · A sudden drop can reduce blood flow to the brain, heart and kidneys
9.Med-surg: cardiovascular & respiratory
Answer: C · Theophylline toxicity
Why this is the answer
Theophylline has a narrow therapeutic window. Toxicity causes nausea, vomiting, tachycardia, arrhythmias, agitation and seizures. Levels are monitored, and many drugs and smoking status change its clearance. The nurse should hold the dose and report.
C · Theophylline toxicity
10.Med-surg: cardiovascular & respiratory
Answer: B · Effective analgesia so they can breathe deeply and cough
Why this is the answer
Pain from rib fractures causes shallow breathing and poor coughing, leading to atelectasis and pneumonia, especially in older adults. Good analgesia (sometimes regional blocks), deep breathing, coughing with support and early mobilisation are key. Chest strapping restricts breathing and is not used.
B · Effective analgesia so they can breathe deeply and cough
11.Med-surg: neuro, endocrine & renal
Answer: B · Heat can briefly worsen MS symptoms, which settle when they cool down
Why this is the answer
Heat sensitivity (Uhthoff's phenomenon) is common in MS. A rise in body temperature slows conduction in demyelinated nerves and temporarily worsens symptoms. It is not a relapse, and the symptoms settle with cooling.
B · Heat can briefly worsen MS symptoms, which settle when they cool down
12.Med-surg: neuro, endocrine & renal
Answer: B · The kidneys clear less insulin, so it lasts longer
Why this is the answer
The kidneys clear a large share of insulin. As kidney function falls, insulin stays in the blood longer and some oral agents build up, so hypos increase. Insulin doses often need to be reduced.
B · The kidneys clear less insulin, so it lasts longer
13.Med-surg: GI, perioperative & oncology
Answer: D · Intrinsic factor from the stomach is no longer made
Why this is the answer
Parietal cells of the stomach make intrinsic factor, which is needed for B12 absorption in the terminal ileum. Without it, pernicious-type anaemia and neuropathy develop unless B12 is given by injection.
D · Intrinsic factor from the stomach is no longer made
14.Med-surg: GI, perioperative & oncology
Answer: A · The usual opioid is continued, plus extra analgesia, due to tolerance
Why this is the answer
Patients on long-term opioids have tolerance and physical dependence. Stopping their usual opioid risks withdrawal and uncontrolled pain. Their baseline dose is continued (or converted to another route) and multimodal analgesia added; they often need more opioid than opioid-naive patients, with careful monitoring.
A · The usual opioid is continued, plus extra analgesia, due to tolerance
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