Adult Medical-Surgical Nursing
This domain tests your ability to recognise a deteriorating adult, prioritise, and anticipate complications of the conditions that dominate Mongolian morbidity: cardiovascular disease, diabetes, tuberculosis, chronic liver disease, and kidney failure on dialysis.
Core rules
- Acute coronary syndrome: 12-lead ECG within 10 minutes of arrival, aspirin 150-300 mg chewed, oxygen only if SpO2 is below 90%. Nitrates are contraindicated after sildenafil or tadalafil, and in suspected right ventricular infarction where they cause profound hypotension.
- DKA versus HHS: DKA has ketones and acidosis at moderately raised glucose; HHS has very high glucose and osmolality with minimal ketones. Both begin with 0.9% saline and a potassium check before insulin.
- Drug-susceptible TB: two months of isoniazid, rifampicin, pyrazinamide and ethambutol, then four months of isoniazid and rifampicin, delivered as DOTS with sputum monitoring and liver checks.
- Stroke: thrombolysis window is 4.5 hours; blood pressure must be below 185/110 before lysis but is not aggressively lowered otherwise.
- Cirrhosis: Mongolia carries one of the world's heaviest hepatocellular carcinoma burdens, driven by hepatitis B and C. Surveillance is six-monthly ultrasound, often with alpha-fetoprotein.
Worked example
A 24-year-old with type 1 diabetes: glucose 28 mmol/L, pH 7.10, ketones 4+, K+ 5.6 mmol/L, BP 95/60. Reasoning: DKA with volume depletion. Give 0.9% saline first, about 1 L in the first hour for an adult, and start insulin at 0.1 units/kg/h only once potassium is confirmed at 3.3 mmol/L or above. Potassium is high now but falls as insulin drives it into cells, so replace early. Add dextrose once glucose drops near 14 mmol/L and continue insulin until ketones clear. Bicarbonate is not routine.
Traps
Starting insulin before fluid in a shocked patient; giving bicarbonate for every low pH; withholding insulin because potassium is high; prescribing nitrates without asking about erectile-dysfunction drugs; assuming stable vitals mean stable disease in a young adult.