Preview Course
View some of our sample questions and get a feel for how your knowledge can build with access to the Ward Ready question bank. Answers, explanations and resource links are located at the bottom of the page.
Ward Calls
You are the night house officer covering the medical ward.
Clare, a 74-year-old woman admitted three days ago with community-acquired pneumonia, is now febrile again at 38.6 °C. Her observations are: HR 110 bpm, BP 102/68 mmHg, RR 22 breaths/min, SpO₂ 94% on 2 L oxygen. Her urine output has fallen over the past 6 hours. She is on IV cefuroxime and oral doxycycline. The nurse calls you because she is “not looking as well as earlier in the day”.
On review, Clare is alert but clammy. Chest exam shows persistent crackles at the right base. Her venous blood gas shows lactate 3.5 mmol/L and pH 7.32.
What is the most appropriate next step in her management?
A) Chart paracetamol and review in one hour
B) Order an urgent chest X-ray and await results before taking further steps
C) Initiate the sepsis pathway, give a fluid bolus, and escalate to the medical registrar
D) Change antibiotics to piperacillin–tazobactam immediately and review again in one hour
E) Prescribe IV fluids and continue current plan, review again in two hours
F) Document the findings and hand over to the morning team
Documentation
John, a 79-year-old man with known ischaemic heart disease, hypertension, and chronic kidney disease, was admitted five days ago with chest pain and dyspnoea. His troponin and ECG showed no acute changes, and he was treated for acute decompensated heart failure. Despite diuretics and oxygen, he deteriorated and died overnight.
You are asked to complete the Medical Certificate of Cause of Death.
Which of the following would be an acceptable entry for line 1(a) (the disease or condition directly leading to death)?
A) Natural causes
B) Circulatory collapse
C) Heart failure
D) Respiratory failure
E) Cardiac arrest
F) None of the above
Investigations
Juno is a 30 year old woman who has a haemoglobin level of 120 g/L (reference range 115 - 155 g/L), and an MCV of 103 (reference range 80 - 90 fL). Which of the following is indicated by this pattern?
A) Macrocytosis without anaemia
B) Microcytosis without anaemia
C) Microcytic anaemia
D) Macrocytic anaemia
E) Normocytic anaemia
Emergency Care
Toni is a 7 year old female presenting with her aunt, who she is currently staying with. She has had a cold for the past 2 days and has been getting more short of breath and constantly coughing. She usually has an inhaler but didn't take it with her to her aunt and uncle's house. On examination she has a loud inspiratory and expiratory wheeze and HR is 140. Oxygen saturations are 91% and there is obvious indrawing between her ribs. What would be the most appropriate treatment of the following?
A) 6 puffs salbutamol via MDI and spacer plus oral prednisolone 1mg/kg
B) 6 puffs salbutamol via MDI and spacer plus oral prednisolone 1mg/kg plus oxygen as required
C) 2 puffs salbutamol via MDI and spacer plus oral prednisolone 1mg/kg
D) 10 puffs salbutamol via MDI and spacer
E) 6 puffs salbutamol via MDI and spacer plus oxygen as required
Answers and Explanations:
Ward Calls = C
Clare’s tachycardia, fever, rising lactate, and reduced urine output indicate sepsis with early organ dysfunction. Immediate escalation is required.
In New Zealand hospitals, standard practice follows the HQSC Sepsis Action Plan: identify sepsis, administer oxygen, obtain IV access, send blood cultures, commence broad-spectrum antibiotics (within 1 hour), give IV fluids (usually 30 mL/kg crystalloid), and monitor urine output. (please check local health pathways)
Simply giving paracetamol or waiting for imaging delays definitive management.
Changing antibiotics without cultures or consultant discussion is premature.
Documentation and deferral without action are unsafe in a deteriorating patient.
Sepsis guides and tools for health professionals
Documentation = F
Line 1(a) should record the specific disease or injury directly leading to death, not a mechanism or symptom.
Unacceptable vague or indefinite terms (from Te Whatu Ora guidance) include “cardiac arrest”, “respiratory failure”, “heart failure”, “multi-organ failure”, “old age”, and “natural causes”. These describe how the patient died, not why.
The correct entry in this case would be ischaemic heart disease or acute decompensated heart failure due to ischaemic heart disease, depending on the clinical evidence.
Mechanisms (e.g., “cardiac arrest”) may appear in all deaths and therefore lack certifying value.
The Medical certificate cause of death must always identify an underlying pathological process initiating the chain of events.
Completing death documents – Health New Zealand | Te Whatu OraMedical Certificate of Cause of Death – Health New Zealand | Te Whatu Ora
Investigations = A
Hb is within normal range (no anaemia), but MCV is elevated (>100 fL), indicating macrocytosis without anaemia.
Macrocytosis without anaemia is a marker to assess underlying causes even if Hb normal.
Causes include alcohol use, liver disease, hypothyroidism, B12/folate deficiency (early), medications.
Other options incorrect because: microcytosis requires low MCV; anaemia requires low Hb; normocytic has normal MCV and Hb.
https://bpac.org.nz/Supplement/2008/May/complete-blood-count.aspx#neutro
Emergency care = B
Toni shows signs of a severe asthma exacerbation:
- Increased work of breathing (intercostal indrawing)
- Tachycardia (HR 140)
- SpO₂ at 91%, indicating need for oxygen therapy
- Audible wheeze on both inspiration and expiration
Recommended acute management in children aged 6 and older includes:
- 6 puffs of salbutamol via MDI and spacer, repeated every 20 minutes in the first hour if needed
- Oral prednisolone at 1 mg/kg once daily, typically for 3 days
- Supplemental oxygen to maintain SpO₂ ≥94% (oxygen is clearly indicated here as Toni's SpO₂ is below 94%).
https://www.asthmafoundation.org.nz/assets/documents/NZ-Asthma-Guidelines-Summary-2020-Digital.pdf