Medical-Surgical Nursing
Medical-Surgical Nursing dominates the blueprint because it is where adult assessment, pharmacology and priority-setting meet. Items reward the nurse who can name the first action and the parameter that must be watched afterwards.
Acute coronary syndrome
Chewed aspirin 300 mg is given early unless contraindicated; oxygen is used only when SpO2 falls below 90%; nitrates are withheld in right ventricular infarction and after recent sildenafil use. Door-to-balloon for primary PCI is 90 minutes and door-to-needle for fibrinolysis is 30 minutes. Troponin rises within 3–6 hours of injury.
Heart failure and electrolytes
Daily weight is the most sensitive home indicator: a gain of 1 kg in a day or 2.5 kg in a week signals fluid retention. Hold digoxin when the apical pulse is below 60/min. In hyperkalaemia with ECG changes, calcium gluconate is given first to protect the myocardium, then insulin with glucose shifts potassium into cells.
Worked example
A patient with type 1 diabetes has glucose 480 mg/dL, pH 7.15, bicarbonate 8 mEq/L, positive ketones and potassium 5.6 mEq/L. Reasoning: this is diabetic ketoacidosis. Give 0.9% saline 15–20 mL/kg in the first hour, then an insulin infusion of 0.1 unit/kg/h; add potassium once the level falls below 5.5 with adequate urine output. Insulin is never bolused before volume resuscitation, because it drives potassium intracellularly and can precipitate a fatal arrhythmia. Bicarbonate is reserved for pH below 6.9.
Traps that cost marks
- Giving potassium before confirming adequate urine output.
- Treating hyperosmolar hyperglycaemic state with the same insulin bolus used in ketoacidosis.
- Forgetting the postoperative fever timeline: day 1–2 atelectasis, day 3–5 urinary infection, day 5–7 wound infection.