Nursing · Adult clinical nursing
One tube open at both ends, and the organ that does too many jobs to fail quietly
Diarrhoeal illness remains among the leading causes of death in children worldwide, and what kills is the fluid and salt lost rather than the organism causing it — which makes one of the cheapest treatments in medicine also one of the most effective. At the other end of the same subject, the gut can hide litres of blood before anything appears, a young patient compensates until they abruptly do not, and the liver fails in five directions at once while looking like five separate problems. Almost everything that decides these outcomes is nursing observation: what went in, what came out, what it looked like, whether the abdomen is distended, and whether the pulse has been climbing while everybody watched the blood pressure.
The digestive tract is a single continuous tube, specialised along its length, open at both ends to the outside world. Understanding it that way makes obstruction obvious to reason about: whatever is above a blockage backs up, whatever is below empties and then stops, and pressure rises behind it until the wall or its blood supply gives way.
Diarrhoeal illness remains one of the leading causes of death in children worldwide, and what kills is the fluid and salt lost rather than the organism causing it. That single fact is why replacing water and salts together is one of the most effective and cheapest treatments in the whole of medicine.
The gut can hold a great deal of blood before anything appears at either end, and a young person compensates until they suddenly do not. A rising pulse in somebody with abdominal pain is bleeding until proved otherwise, and waiting for a falling blood pressure is waiting too long.
It makes clotting factors and plasma proteins, processes everything absorbed from the gut, stores glucose, produces bile and removes substances the body must be rid of. When it fails, bleeding, swelling, jaundice, unstable glucose and confusion appear together, looking like five problems from one organ.
What somebody has eaten, whether they vomited, what it looked like, whether they opened their bowels, what that looked like, whether the abdomen is distended, and whether they are passing flatus. None of it needs equipment, all of it changes decisions, and all of it depends on somebody asking and writing it down.
A distended abdomen, visible peristalsis, an obvious hernia, bruising around the flanks or navel, surgical scars, and whether the patient is lying very still or cannot keep still are all visible before any hand is laid on. A patient who lies rigidly still is protecting a peritoneum that is inflamed.
Pain that began centrally and moved to the lower right is the classic appendix description, and the movement matters more than either location alone. Pain that has changed character — from colicky to constant, or from vague to severe and localised — is a deterioration being reported in a way people do not recognise as urgent.
Colicky pain comes in waves and reflects a hollow tube contracting against something. Constant pain that is worse on movement suggests inflammation of the lining of the abdomen. Those two behave differently, mean different things, and are distinguished by asking rather than by any test.
Pulse, blood pressure, temperature, urine output and how the person looks matter as much as the abdomen itself. A soft abdomen in somebody with a rising pulse and falling output is a more worrying combination than a tender abdomen in somebody entirely stable.
Whether somebody has opened their bowels, passed flatus, vomited and what it contained are clinical findings that only exist if a nurse asks and records them. After abdominal surgery, the first passage of flatus is genuinely informative, which is why the question is asked so persistently.
Undigested food suggests a problem high up. Bile-stained vomit suggests below the stomach outlet. Vomit that smells faecal suggests a low obstruction. Blood, either fresh or looking like coffee grounds, suggests bleeding from the upper tract, and that is an emergency rather than a symptom.
Vomiting accompanies raised pressure in the skull, heart attack, diabetic emergencies, kidney failure, pregnancy, infection anywhere, and many medicines. Assuming the cause is in the abdomen is how a head injury and a heart attack get missed.
Prolonged vomiting loses water, salts and acid from the stomach, producing dehydration and a disturbance of the blood's salt and acid balance. The record of how much, how often and for how long is genuinely clinical information rather than administrative detail.
Somebody vomiting with reduced consciousness can aspirate, and that is the mechanism behind a large amount of avoidable pneumonia. Position matters more than anything else available, and a drowsy patient who is vomiting is not left flat on their back.
Vomiting is frightening and exhausting, and treating it is not optional comfort. Mouth care afterwards, small sips once it settles, a bowl within reach, and privacy are all part of the care, and a patient who has vomited into their own bedding while waiting has been failed.
Persistent nausea is more distressing to many patients than actually vomiting, because it does not resolve and it removes any appetite. It stops people eating, drinking and taking tablets, so it quietly undermines every other part of a treatment plan while being recorded as a minor complaint. Asking about it directly, and treating it rather than waiting for vomiting to justify attention, changes whether somebody can eat at all.
Water alone does not correct what has been lost and can make the salt disturbance worse. Oral rehydration containing salts and sugar works because sugar and sodium are absorbed together, carrying water with them, through a mechanism that continues to work even when the gut is inflamed.
A sick child needs more nutrition, not less, and withholding food during diarrhoeal illness worsens outcomes and deepens the cycle of infection and undernutrition. Continued feeding alongside rehydration is the standard, and it is the part most often got wrong by well-meaning advice at home.
Alertness, thirst, sunken eyes, the mouth, skin that stays pinched, urine output and, in an infant, a sunken fontanelle and absent tears. These are assessed together because no single one is reliable, and they were chosen precisely because they need no equipment.
Blood in the stool, high fever, severe abdominal pain, or diarrhoea in somebody who has recently had antibiotics all change the picture. That last one matters because disturbance of gut flora can allow a severe bowel infection that spreads easily and requires specific precautions.
Hand hygiene with soap, safe water, safe food handling and safe disposal of stool prevent spread within a household far more effectively than anything given to the person already ill. Teaching that at the point of care is where most of the benefit lies.
Immobility, dehydration, poor intake, unfamiliar surroundings, lack of privacy and many medicines cause it, and it produces pain, confusion in older patients, urinary retention and occasionally obstruction. Asking about bowels in an unwell older person frequently explains the whole presentation.
Fibre works by holding water and adding bulk. Increasing it without increasing fluid produces a bulkier, drier stool and a more uncomfortable patient, which is a genuinely common and entirely avoidable error on wards.
Nobody opens their bowels comfortably on a bedpan behind a curtain with a queue outside. Getting somebody to a toilet or a commode, with feet supported and time that is not rushed, does more than most things given for the problem.
Loose stool in somebody who has been constipated may be liquid passing around a hard impacted mass rather than diarrhoea. Treating that as diarrhoea and stopping laxatives makes it worse, and the distinction is made by examination and by history rather than by the appearance alone.
Anybody immobile, on strong painkillers, dehydrated, or recently operated on will become constipated unless something is done about it. Preventing it is far easier than treating it, and it is one of the clearest examples of nursing anticipating rather than reacting.
Vomiting blood, or material like coffee grounds, and black tarry stool point to bleeding high in the tract. Fresh red blood from below usually points lower down, although a very brisk upper bleed can also appear red. The distinction guides urgency and investigation.
Digested blood turns stool black, sticky and distinctively foul-smelling. A patient reporting that without any pain may have lost a great deal, and it is a finding to escalate rather than to note. Iron tablets also blacken stool, which is why the description and the smell matter.
Young and previously healthy people compensate for substantial blood loss with a rising pulse and a normal blood pressure, then deteriorate abruptly. A normal pressure in somebody who has vomited blood is not reassurance, it is the reserve that has not yet run out.
Scarring in the liver obstructs blood passing through it, so pressure rises behind and forces open fragile alternative veins at the lower oesophagus. Those can bleed catastrophically and suddenly, which is why a known liver patient vomiting blood is an emergency of a different order.
Sit them up if they are vomiting, protect the airway, call for help, obtain access, take observations including a pulse that is counted, keep them nil by mouth, and stay with them. Blood loss here is measured in how the patient looks and how their pulse moves.
Colicky pain as the gut contracts against a blockage, vomiting, distension, and an absence of flatus and stool. How early each appears depends on how high the obstruction sits: high obstruction vomits early and distends little, low obstruction distends a great deal and vomits late.
Litres can be sequestered inside an obstructed bowel, so the patient becomes profoundly dehydrated while apparently only being unable to eat. That hidden loss is why these patients need fluid replacement urgently and why their observations deteriorate faster than the abdomen suggests.
When the blood supply is caught in the obstruction — a twisted bowel, a strangulated hernia — the tissue dies. Pain out of proportion to the examination, tenderness, and a patient who is systemically unwell distinguish this from a simple blockage, and it is surgical rather than observational.
A tube passed into the stomach drains what is backing up and relieves vomiting and distension. Measuring and recording what drains matters, because the volume is part of the fluid balance that is keeping the patient alive.
Bowel sounds that are high-pitched and active early, then absent later, track the natural history of an obstruction. But the more reliable nursing observation is simpler: has anything passed, in either direction, and when.
Pain from the appendix is initially felt centrally because of how the organ's nerves enter the cord, and it shifts to the lower right when the inflammation reaches the lining of the abdominal wall. That migration is more useful diagnostically than either location on its own.
Pregnant women, in whom the appendix is displaced upwards by the uterus, older people, and small children who cannot localise pain. In each of those groups the diagnosis is made later and perforation is more common, which is a recognition problem rather than a disease problem.
A patient whose severe pain suddenly eases may have perforated, releasing the pressure, and will deteriorate over the following hours. Sudden relief without treatment is not improvement, and it is one of the classic misreadings in abdominal assessment.
Withholding analgesia to avoid masking signs was taught for decades and is not supported. Leaving somebody in severe pain while waiting for a decision is unnecessary, and appropriate pain relief does not prevent the diagnosis being made.
Ovarian problems, ectopic pregnancy, urinary infection, stones and inflammatory bowel disease all present similarly. A pregnancy test in any woman of childbearing age with abdominal pain is not optional, and it is the omission most often found in reviews of missed diagnoses.
Chronic inflammatory bowel conditions cause diarrhoea, blood, abdominal pain, weight loss and profound fatigue, in a pattern of flares and remissions. They usually begin in young people, they are lifelong, and the fatigue is the symptom patients rate as worst and clinicians ask about least.
Urgency — needing a toilet within moments — dominates these patients' lives, dictating where they go, what they do and whether they travel. Asking about it directly, and helping with practical arrangements, addresses more of the disability than anything else in the consultation.
Symptoms without visible damage are not imaginary, and telling somebody there is nothing wrong after months of pain is both inaccurate and damaging. It is a genuine disorder of gut function, and it responds to specific approaches rather than to reassurance.
An immune reaction to a protein in wheat, barley and rye damages the lining of the small intestine and causes malabsorption, anaemia, fatigue and poor growth. Testing must happen while the person is still eating the protein, which is why advising somebody to cut it out before testing destroys the diagnosis.
Where bowel is diverted to the surface, learning to manage it changes body image, clothing, diet, intimacy and confidence in leaving home. Practical teaching and a specialist nurse matter more to the outcome than the surgery itself, and the first weeks determine whether somebody copes.
Yellow appears when the pigment from broken-down red cells accumulates. Too many cells breaking down, a liver that cannot process it, or bile that cannot escape produce the same colour and quite different everything else. Pale stool and dark urine point towards obstructed bile flow.
One group of blood tests says whether liver cells are being damaged. Another — clotting, albumin, bilirubin — says whether the liver is still doing its work. A patient can have dramatically abnormal enzymes with a functioning liver, and the reverse, which is why they are read as two questions.
Substances the liver would normally remove accumulate and affect the brain, producing a fluctuating confusion frequently mistaken for dementia, intoxication or unhelpfulness. It is usually precipitated by something identifiable — bleeding, infection, constipation, dehydration — so the nursing question is what changed.
Scarring obstructs blood flowing through the liver, pressure rises behind it, and fluid is forced into the abdominal cavity. It is uncomfortable, it splints the diaphragm and makes breathing harder, and it can become infected, which presents as fever and worsening confusion rather than as abdominal pain.
Asking about alcohol without judgement, in units people recognise, and without visible reaction to the answer, is what produces an honest number. A defensive or moralising question produces an underestimate, and the underestimate is then what the whole plan is built on.
Some viral hepatitis spreads through contaminated food and water, and some through blood, sexual contact and from mother to child. The route determines the prevention entirely, which is why grouping them under one name causes so much confusion about what precautions actually apply.
Certain hepatitis viruses can remain for life, quietly scarring the liver and eventually causing failure or cancer decades later. Because the early years are silent, finding them depends on testing people at risk rather than waiting for symptoms.
Vaccination exists for some, safe water and sanitation prevent others, and safe injection practice, screened blood and precautions at birth prevent the blood-borne ones. Each is a different intervention and applying the wrong one is a common and consequential error.
Health workers are exposed through needles and sharps, and vaccination plus safe sharps practice is what protects them. Reporting an exposure immediately matters because some preventive treatment is time-critical, and the commonest failure is not reporting at all.
A hepatitis diagnosis carries real social consequence in many communities, affecting work, marriage and family. Confidentiality is therefore a clinical matter as well as an ethical one, because a service known to be discreet is a service people will actually attend.
Inflammation of the pancreas causes severe upper abdominal pain radiating to the back, with vomiting, and a patient who may find it eased by leaning forward. It can be mild or it can be a life-threatening illness with organ failure, and the early hours do not reliably predict which.
Large volumes of fluid are lost into the inflamed tissue, so these patients need aggressive fluid replacement and close monitoring of urine output in the first hours. Managing the pain without managing the fluid is how a survivable illness becomes a fatal one.
Stones in the gallbladder cause severe right upper pain after fatty food, which settles. When the pain does not settle, and fever appears, the gallbladder itself is inflamed. When jaundice appears too, a stone has moved into the duct and is obstructing bile.
Gallstones and alcohol account for most pancreatitis worldwide. Establishing which, without judgement, determines whether the treatment is surgery on the gallbladder or support to stop drinking, and getting that history is a nursing conversation as much as a medical one.
Prolonged starvation was once standard and is no longer supported for most patients. Early feeding, usually into the gut, is associated with better outcomes, and a nurse who is asking when feeding will start is asking a current question rather than an impatient one.
Feeding into the gut maintains its lining, supports its immune role and carries fewer serious complications than feeding into a vein. Deciding not to use a working gut requires a reason, and a patient who is simply not eating enough is not automatically a patient who needs a tube.
A feeding tube that has entered the airway and is then used delivers liquid directly into a lung. The defence is the verification method local policy specifies, followed without shortcut, before every use — not the absence of coughing during insertion, which proves nothing.
Somebody who has eaten very little for a long period can be seriously harmed by being fed too quickly, as the shift back to using food drives salts rapidly out of the blood. Recognising who is at risk and feeding cautiously under supervision is what prevents it.
When the gut genuinely cannot be used, nutrition can be given directly into the bloodstream. It carries real risks, particularly infection at the line and disturbances of glucose and salts, and it demands strict handling of the line rather than ordinary care.
A patient being fed by tube still has a mouth that dries, cracks and grows organisms, and what is aspirated is whatever is growing there. Mouth care for somebody who is nil by mouth is more important than for somebody eating, and it is the task most often dropped.
The passage for air and the passage for food cross at the back of the throat, and a flap closes over the airway during swallowing. That arrangement is the entire reason aspiration exists, and why anything weakening the swallow — stroke, dementia, sedation, reduced consciousness, a very dry mouth, a nasogastric tube — puts food and fluid into the lungs instead of the stomach.
Coughing during or after eating, a wet or gurgling voice afterwards, food remaining in the mouth, taking a very long time over a meal, refusing particular textures, and repeated chest infections with no other explanation. Some people aspirate silently and never cough at all, which is why unexplained chest infections should prompt the question even when eating looks untroubled.
Sit the person fully upright and keep them upright afterwards, remove distractions, give small amounts, allow time, check the mouth is empty before the next mouthful, and stop if there are signs of difficulty. Mouth care matters more here than almost anywhere, because if material is aspirated the risk depends heavily on what is growing in the mouth at the time.
Formal assessment of swallowing belongs to somebody trained to do it. Deciding independently to thicken fluids, to withhold food, or to continue feeding a patient who is visibly coughing are all decisions outside that boundary, and this manual states the boundary rather than blurring it.
A narrowing in the oesophagus, a tumour, inflammation from reflux, or a pouch that collects food all cause difficulty swallowing. Progressive difficulty with solids first, then liquids, in an older person losing weight, is a pattern that needs investigation rather than a modified diet.
A muscular ring where the oesophagus enters the stomach normally stays closed. When it is weak, or when pressure inside the abdomen is high — obesity, pregnancy, a large meal, lying flat after eating — stomach contents pass upwards. That is why raising the head of the bed and not lying down after food are treatments rather than suggestions.
Repeated exposure inflames the lining of the oesophagus, and over a long period the cells there can change into a different type better suited to acid. That change carries a small but real risk of becoming cancer, which is why long-standing severe reflux is investigated rather than simply medicated indefinitely.
Difficulty swallowing, food sticking, weight loss, vomiting blood, anaemia, or new symptoms in somebody older are not features of simple reflux and are the reason a person is examined rather than reassured. Treating all upper abdominal burning as indigestion is how oesophageal and stomach cancers are found late.
A common bacterial infection of the stomach lining causes ulcers and is linked to stomach cancer, and it can be tested for and treated. That transformed a condition once managed with milk and rest into one that is frequently cured, and it is a good example of how completely a subject can change.
Pain from the heart and pain from the upper abdomen overlap enough that people having a heart attack take antacids and people with reflux fear their heart. Anybody with upper abdominal pain, sweating or breathlessness is assessed for a cardiac cause first, because that is the one that cannot wait.
The great majority of gut infections resolve with fluid replacement and time, and the clinical work is keeping somebody hydrated and recognising the minority that do not. Antibiotics are frequently unnecessary and occasionally make things worse, which is why the treatment for most of it is water, salts and food.
Blood in the stool, high fever, severe abdominal pain, a very unwell patient, or somebody whose immunity is reduced. Each of those moves a case out of the ordinary and into one that needs assessment, stool testing and a different level of concern.
Disturbing the gut's normal flora can allow a severe bowel infection to take hold, producing profuse diarrhoea in somebody recently treated with antibiotics. It spreads readily on hands and surfaces, and alcohol rub does not reliably kill it — soap and water are needed, which is one of the few situations where that distinction matters urgently.
Somebody with infectious diarrhoea needs their own toilet facilities where possible, meticulous hand hygiene with soap, thorough cleaning of surfaces, and gloves and aprons used properly rather than worn continuously. An outbreak on a ward is usually recognised by a nurse noticing the third case that week and saying so.
Most food-borne illness comes from a short list of failures: unwashed hands, raw and cooked food in contact, inadequate cooking, food left warm, and unsafe water. Each is addressed by a simple teachable practice, which is why this is a community health subject as much as a clinical one.
A change in bowel habit lasting weeks, blood in the stool, unexplained weight loss, difficulty swallowing that is getting worse, persistent vomiting, or new anaemia in an older person. Each of these is ordinary enough to be dismissed and specific enough to matter, and dismissal is how these cancers are found late.
Iron deficiency anaemia in an older adult, particularly a man or a woman past the menopause, means blood is being lost slowly from somewhere, and the digestive tract is the usual place. Treating the anaemia with iron without asking where the blood went is a well-recognised and costly omission.
Programmes that test stool for hidden blood, or examine the bowel directly, detect cancer at a stage when it is curable and find growths that can be removed before they become cancer. Uptake is the limiting factor everywhere, and the reasons people decline are practical and addressable rather than ignorant.
Bowel preparation is unpleasant, the test is embarrassing, and people avoid it for reasons they rarely say aloud. Explaining exactly what will happen, what it will feel like, how dignity is protected and how long it takes, changes attendance more than explaining the importance of it does.
Surgery may leave somebody with a stoma, altered bowel habit, changed diet, fatigue and fear of recurrence. The practical teaching in the first weeks determines whether a person manages, and a specialist nurse contributes more to that outcome than almost anything else in the pathway.
Explaining what will happen, what the wound will look like, what tubes they will wake with, how the pain will be managed, and when they will be expected to move. A patient who wakes with a tube nobody mentioned spends the first day frightened, and fear costs mobility and breathing.
Patients are fasted for theatre and then routinely fasted again when the list is delayed. Repeated or prolonged fasting, particularly in frail and older patients, is a measurable and avoidable harm, and asking whether a delayed patient may now eat or drink is squarely nursing work.
Anaesthesia, pain, immobility and a wound that hurts to cough around reduce the depth of breathing, so areas of lung collapse and secretions collect. Adequate pain control, sitting upright, supporting the wound while coughing and early walking do more for the chest than anything given for it.
Bowel activity stops for a period after abdominal surgery and returns gradually, which is why the first passage of flatus is asked about so persistently. Prolonged absence with distension and vomiting is a complication rather than a delay, and the distinction is made by trend rather than by a single day.
Redness spreading beyond the wound edge, increasing pain, discharge that has changed, a wound that was closing and has stopped, or a sudden gush of fluid after straining all matter. A wound that opens deeply after abdominal surgery is an emergency, and it is covered and escalated rather than examined repeatedly.
Fever, infection, surgery and inflammation all increase energy and protein requirements at precisely the time somebody is nauseated, fasted for procedures and unable to face food. That mismatch is how patients with gut conditions become malnourished while being treated for the very organ that feeds them.
A person can eat adequately and still be starving if the small intestine cannot absorb, which happens in coeliac disease, after bowel resection, in chronic pancreatic disease and in some infections. Weight loss with a good appetite is the pattern that separates this from simply not eating enough.
A chart recording delivery can look complete while a patient eats almost nothing for days. The clinically useful entry is what was actually consumed, in plain words, and it is the only record that lets anybody see a decline before the weight does.
Low residue, gluten free, low fat and modified texture diets each exclude a great deal of ordinary food and collide with how households actually cook. A plan that ignores what a family eats is abandoned, and the patient is then recorded as non-compliant for a failure that belonged to the plan.
Sore mouth, ulcers, thrush, ill-fitting dentures and a dry mouth all stop people eating, and all are found by looking. It is the examination most often skipped because it feels intrusive, and it is frequently the whole explanation for somebody who has stopped eating.
A section of bowel brought to the surface of the abdomen so that its contents leave into a bag rather than through the rectum. It has no sensation and no muscle to control it, so output happens without warning — which is the single fact that patients find hardest and that determines most of what has to be taught.
A stoma formed from the small intestine produces looser, more frequent, more corrosive output in larger volume, and carries a real risk of dehydration and salt loss. One formed lower in the colon produces something more formed and less frequent. The site therefore changes the diet, the bag, the fluid advice and the risks.
Output on skin causes rapid breakdown, and sore skin makes the bag leak, which causes more sore skin. Getting the aperture the right size, the skin properly dry before application, and a good seal is the whole of prevention, and it matters more to a patient's daily life than almost anything else.
A person who learns to change their own bag confidently before discharge manages. One who is discharged having watched somebody else do it does not, and returns in distress. Teaching means watching them do it themselves, more than once, and finding out whether they can see, reach and grip what is required.
People worry about smell, noise, whether it shows through clothing, swimming, and sex, and almost none of them raise it. Saying these things out loud without being asked, matter-of-factly, is one of the most useful things a nurse does in this subject and one of the least often done.
Where endoscopy and imaging are not available within hours, the sequence of events, the character of the pain, what has been passed and how the observations have moved over time become the assessment rather than a preliminary to it. Being genuinely good at that is a skill, not a fallback.
In diarrhoeal illness, in obstruction, in bleeding and in pancreatitis, the fluid is what keeps somebody alive while the cause is addressed. Oral rehydration needs almost nothing, works when the gut is inflamed, and is available in settings with no laboratory at all.
Where definitive care is hours away, the decision is made while the patient is still stable enough to travel, because the journey consumes the time a deteriorating patient does not have. Delay in deciding is the classic contributor to death in every review of these systems.
Safe water, safe food handling, handwashing with soap, safe disposal of stool, and vaccination prevent far more gastrointestinal death than any hospital in these settings will treat. Community teaching is not a lesser activity than clinical work here; it is the higher-yield one.
Writing that a patient could not be investigated because the service was unavailable, rather than leaving a gap, is what makes the shortage visible to anybody who can address it. A review that concludes staff needed more training when the ward had no functioning suction has recorded a falsehood.
Oral rehydration and continued feeding in childhood diarrhoea, recognising gut bleeding, obstruction, the migrating pain of appendicitis, and tube position before feeding. The questions are scenarios and they reward the order of actions.
Treating loose stool in a constipated patient as diarrhoea; reading sudden relief of severe abdominal pain as improvement; withholding analgesia to avoid masking signs; omitting a pregnancy test in a woman with abdominal pain; trusting an absence of coughing as proof of tube position.
Assess the whole patient rather than the abdomen, replace fluid, keep them nil by mouth where obstruction or bleeding is suspected, escalate early, and document what was passed and when. Answers that investigate before resuscitating lose marks.
Ask what came out and what it looked like. Count the pulse yourself in anybody with abdominal pain. Ask about bowels in every confused older patient. Do the mouth care on the patient who is nil by mouth. Verify the tube every time.
In any abdominal patient, the trend across a few hours — pulse, pain character, distension, what has passed — tells you more than any single examination. Recording that series is what makes the deterioration visible to whoever comes next.
Written in plain sentences on purpose. Nursing is studied in a second language by a large share of the students who will read this, and a sentence that has to be decoded twice is a sentence that teaches less.
These are the twelve questions written with this SUNYRA nursing manual, to check what it teaches. They are not past papers and were not written to any one examination's pattern; an examination tag means only that the examination's published blueprint covers this subject. Difficulty was not graded in the source, so every question is marked medium.
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