Reading A02

Reading A02
Text A

Overview
Intravenous (IV) cannulation is a technique in which a cannula is placed inside a vein to provide
venous access.

Indications
Indications for IV cannulation include the following:
• repeated blood sampling
• fluid administration
• medications administration
• chemotherapy administration
• nutritional support
• blood or blood products administration
• administration of radiologic contrast agents for computed tomography (CT), magnetic
resonance imaging (MRI), or nuclear imaging

Contraindications
No absolute contraindications to IV cannulation exist but avoid injured, infected, or burned
extremities if possible. Some vesicant and irritant infusions (pH < 5, pH >9, or osmolarity >600
mOsm/L) can cause tissue necrosis if they leak into the tissue, including sclerosing solutions, some
chemotherapeutic agents, and vasopressors. These fluids are more safely infused into a central
vein. They should only be given through a peripheral vein in emergency situations or when a
central line is not readily available.

Text B

Technique
After skin preparation, use a tourniquet to
increase the venous pressure and pull skin
taut in opposite direction of needle insertion.
Avoid excessive pressure to cannulation site
to prevent flattening of vessel.
For an easily palpated vessel, use
approximately 25° angle with the bevel up.
Once vessel has been penetrated
• Advance the needle slowly with the
cutting edge facing the top of the vessel
and do not rotate the axis
Rationale
Increases surface tension so facilitates
smoother incision of skin with less surface
area contacting cutting edge of needle.
Less steep angles increase the risk of needle
cutting along surface of vessel. Steeper
angles increase risk of perforating the back
wall of the vessel.
Any manipulation may traumatise the intima
of the vessel. The use of a back-eye needle
will eliminate the need to rotate the needle
due to poor flows.

• Tape the needle at the same angle or
one similar to the angle of insertion
• Remove needle at angle similar to
angle of insertion and never apply
pressure before the needle is
completely out.
Pressing the needle shaft against the skin
moves the needle tip from the desired
position within the vessel.
Avoid trauma to the intima by dragging the
cutting edge along it.

Text C
 Reading A02
Size Flow rate Recommended use
14G 300ml/min For patients in shock, e.g. GI bleeds or trauma. Also for peripheral
16G 200ml/min administration of amiodarone, dopamine.

18G 90ml/min For blood transfusions or high volume infusions.

20G 61ml/min Multi-purpose IV; for medications, hydration and day-to-day therapies.
22G 36ml/min For patients with small veins; elderly or paediatric patients. Only for use
with saline, standard antibiotics and heparin.

Text D

Phlebitis is associated with IV therapy, and can occur in as many as 70% of patients. It is
defined as the acute inflammation of the internal lining of the vein. Phlebitis is characterised by
pain and tenderness along the course of the vein, redness and swelling, and warmth can be
felt at the insertion site.

Phlebitis Scale

Grade Clinical Criteria

0 No symptoms at access site
1 Erythema
2 As 1, plus pain
3 As 2, plus streak formation and a palpable venous cord
4 As 3 with a palpable venous cord > 1 inch in length and purulent drainage

Prevention measures include:

• Adhering to aseptic technique during insertion, dressing changes, mixing or drawing up
of solutions or medications, accessing ports or hubs on IV equipment.
• Cannula site rotation.
• Using the smallest gauge cannula in the largest vein.
• Adequate securement of the IV device.
• Close and regular monitoring of the IV site.
• Patient education of the signs and symptoms of phlebitis.
• Following guidelines on dilution of solutions to prevent particulate matter and to ensure
that the medication or solution doesn’t have too high or too low a pH.
 Reading A02
Part A: Questions

Questions 1 – 8
For each question below, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once.

In which text can you find information about

1 when it’s better not to insert an IV cannula? ______

2 a frequent complication associated with cannula use? ______
3 how to decide which is the most appropriate cannula? ______
4 ways of keeping a cannula site healthy? ______
5 the correct way to insert a cannula? ______
6 using cannulas to help with diagnosis? ______
7 a ranking system to help judge the seriousness of a problem? ______

Questions 8 – 14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

8 What size cannula should you use on children?

____________________________________________

9 What is the best size cannula to use for routine treatments?

____________________________________________

10 What can happen if you use excessive pressure when inserting the needle?
____________________________________________

11 What size cannula should you use to administer a large quantity of fluids?
____________________________________________

12 What kind of needle should you choose to ensure you don’t have to twist it after
insertion?
____________________________________________

13 What part of the blood vessel is at risk of damage while you are taking the needle
out?
____________________________________________

14 What part of the vein is affected in phlebitis?

____________________________________________
 Reading A02

Questions 15 – 22
Complete each of the sentences, 15-22, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both.

Inserting the cannula

15 When preparing to insert a cannula, clean the skin and then apply a
_________________________
16 Inserting the needle too steeply can result in _________________________ the
underside of the vein.
17 When you are pushing the needle into the vein, keep the __________________
face up.
18 When securing the IV device, make sure the __________________ of the needle
remains as it was when you inserted it.

Assessing and avoiding complications

19 If the patient’s only symptom is _________________________, then they have
grade 1 phlebitis.
20 Make sure that there is no _________________________ in IV solutions that you
make up.
21 Make sure you stick to _________________________ working practices when
handling IV equipment.
22 The presence of a thickened vein together with ____________________tells you
the patient has grade 4 phlebitis.
 Reading B01

Reading B01

According to the update, allergens do not need to be written on packaging if

A the medicine is intended to be taken by mouth.

B medicine administration is unlikely to result in a reaction.
C there is a small amount of the allergen in the medicine.

Update: Improved labelling for allergens

Health professionals are advised that new rules are being implemented for
medicine labels to include improved information about potential allergens.
While certain allergens, such as peanuts and gluten, were already required on
medicine labels, the new rules include a longer list of substances that must be
declared. The additional substances include crustacea, fish, eggs, soya, milk
and tree nuts. In some circumstances, allergens do not need to be declared on
the medicine label. For example, some substances may only cause a reaction if
they are administered orally and therefore don't have to be declared if the
medicine is only for topical use, and some substances are only declared if
there is a certain amount in the product.

Word count: 122

 Reading B02

Reading B02

The manual extract explains that correct specimen handling

A contributes to high test results.

B protects the integrity of testing.
C ensures use of the right needle.

Specimen collection

Test results will be useless or misleading if testing is not performed on a valid

specimen. A valid specimen is one that is:
- collected from the correct patient, into the correct container.
- not contaminated by IV fluid. Contamination can cause high results (infusion of
a concentrate), low results (specimen dilution) or can have unpredictable
effects, such as drug interference.
- not haemolysed. Haemolysis results in the release of cellular components
(notably potassium) into the plasma/serum and can also cause interference
with some test methods. In vitro haemolysis can be caused by using
excessive force when withdrawing blood in a syringe or by use of a small bore
needle.

Page 1 of 2
 Reading B03

Reading B03

The email explains that ongoing professional development must be demonstrated

by

A sending evidence to the Board on a yearly basis.

B recording the details of the activities undertaken.
C completing the form attached to the email.

To all nursing staff: Professional development

We are writing to remind the nursing and midwifery staff of the need to keep track
of your Continuing Professional Development (CPD) by filling in a record sheet of
your activities for the year. The attached template can be used; alternatively, you
can devise your own.

While you do not need to submit evidence of your CPD to the Nursing and
Midwifery Board annually, you will be required to sign a declaration that you have
completed the necessary hours. Staff must keep the evidence of CPD attendance,
such as dates, number of hours, enrolment forms and payment, score sheets and
certificates of participation, for three years in case of an audit. The Board reserves
the right to randomly select a number of their registrants to audit each year.

Page 1 of 2
 Reading B04

Reading B04

In order to minimise the negative effects of heat, the extract recommends

A monitoring the residents’ cardiovascular health.

B disposing of drugs that have become toxic.
C following medication storage instructions.

Residential aged care – hot weather guide

Care planning for residents during hot weather should include consultation with
their general practitioner and pharmacist regarding the use and storage of
medications, as some can become toxic or less effective when exposed to high
temperatures.
Dehydration and cardiovascular responses to heat can affect drug concentrations
and actions. Residents’ serum blood levels may require additional monitoring
during hot weather to avoid toxicity of medications with a narrow therapeutic index,
such as lithium, digoxin and some antiepileptic drugs.
Exposure to high temperatures can adversely affect the efficacy and decrease the
shelf life of some medications. It is important that all medications are stored and
transported at appropriate temperatures as indicated by the manufacturer’s
instructions on the packaging.

Page 1 of 2
 Reading B05

Reading B05

The main point of the guideline extract is that

A new protocols on patient-related outcomes should be followed.

B clinical trials related to chronic diseases should not be relied upon.
C patient preference should be considered when deciding on treatment.

Patient choice and treatment of chronic diseases

Patients’ own perceptions of their quality of life and quality of health, and their
preferences, are extremely important elements of the assessment of therapy. However,
they are often an underappreciated and/or unmeasured parameter in the evaluation of
many clinical trials. The patient’s perspective in relationship to real or perceived impact on
their quality of life is particularly relevant when considering the risks and benefits of
interventions. The recently introduced patient-related outcomes, which allow a more rapid
assessment, have the potential to provide a uniform quality-of-life determination that is
standard across all chronic diseases.
 Reading B06

Reading B06

The guideline states that the preferred test for glomerulonephritis

A reveals how proteinuria levels vary.

B reflects protein output over a period of time.
C is the most accurate measurement of urine albumin.

Guideline: Proteinuria in glomerulonephritis

There is debate about whether urine albumin or urine protein excretion is the preferred
measurement to assess glomerular injury. However, 24-hour protein excretion remains the
reference (‘gold standard’) method for quantification of proteinuria in patients with
glomerulonephritis. It averages the variation of proteinuria due to the circadian rhythm,
physical activity and posture. Almost all of the published clinical trials used in the
development of this guideline utilised 24-hour measurement of proteinuria to assess
responses. A random (‘spot’) urine sample, or a first morning urine sample, is a practical
alternative to 24-hour urine collection. It is increasingly used in clinical practice because
the sample is easy to obtain, and is not influenced by variation in water intake or by
urinary flow rate.
 Reading C01

Reading C01

Text: 1 Umbilical cord blood banking in Australia: Public good or private gain?

Allogeneic haematopoietic stem cell transplantation (HSCT) is a curative therapy for many
malignant and non-malignant conditions, including leukaemia, bone marrow failure
syndromes, immunodeficiencies and inborn errors of metabolism. Unfortunately, only 30% of
patients in need of HSCT will find a suitably matched related donor. The only option for other
patients is to search for an unrelated volunteer donor. Over the past decade, these
difficulties have led to umbilical cord blood (UCB) being increasingly used as an alternative
source of stem cells for HSCT in patients who do not have a matched bone marrow or blood
donor. Over 7000 UCB transplants have now been performed worldwide, with more than
150 paediatric UCB transplants performed in Australia alone. Successful UCB transplant
programs have led to the establishment of two types of UCB banks: public banks and for-
profit private banks. In the case of Australia, I argue that there is adequate social and
medical justification for public UCB banks; however, based on current knowledge of the
therapeutic uses of UCB stem cells, private UCB banking is not similarly justified.

The two types of UCB banks in Australia differ in both their scientific rationale and their
medical utility. Public UCB banks are altruistic, store donated UCB for public access, and are
analogous to volunteer bone marrow donor registries. In contrast, private UCB banks will,
for a fee, store a child’s UCB for personal or family use. It should be noted that transplant
centres themselves also store directed family UCB donations if a family member is known to
have (or potentially has) a disease that can be treated with transplantation. Public UCB
banks have, for the most part, been very successful in making HSCT a real option for
Australian patients who require a transplant. These banks attract considerable public support
and donation from a broad range of Australians. However, there are a number of political
and structural challenges facing public UCB banking in Australia.

Firstly, collecting and storing UCB is expensive and requires considerable and continuous
government support. In addition, there are only a limited number of collection centres and
these tend not to be located in regional or culturally diverse areas, resulting in continued low
donation and recruitment rates from ethnic minority and indigenous groups. Although
Australian public UCB banks show significantly more ethnic diversity than their bone marrow
registry counterparts, public UCB banks are still characterised by under-representation of
many ethnic groups, particularly Aboriginal Australians and Pacific Islanders. Given the
increase in UCB transplantation and the persistent under-representation of indigenous
Australians and ethnic minorities in UCB banks, recruitment strategies that best meet the
 Reading C01

needs of potential transplant recipients need to be developed. This will not be a simple task,
as such policies must take account of equity concerns and specific population needs.

In contrast to public UCB banking, questions have been raised about the assumptions upon
which private UCB banking is based. These assumptions include: that UCB will provide a
valuable and appropriate resource for use in transplantation and regenerative medicine; that
stem cells present in UCB could not easily be collected from other sources (e.g., from
peripheral blood or bone marrow) at the time that they are needed; and that the likelihood of
needing UCB stem cells is sufficiently great to justify the expense of long-term storage of
UCB. Each of these assumptions is questionable — the promise of regenerative medicine is
yet to be shown in clinical trials; the conditions for which HSCT is performed often require
stem cells from allogeneic sources rather than from the patient, and stem cells can generally
be obtained from alternative sources when required for HSCT; and the vast majority of
people will never develop a haematological malignancy or any other indication for HSCT, so
will never require the use of their own haematopoietic stem cells (estimates of the likelihood
of requiring one’s own stem cells for autologous transplantation later in life vary between 1 in
20,000 and 1 in 200,000).

Much of the excitement surrounding UCB research is based on hope, rather than evidence.
However, should UCB stem cells prove to have wider therapeutic application, another set of
different but equally serious questions will surely arise regarding the maintenance of social
equity in health care. For example, only a small proportion of the population may be able to
afford UCB storage for personal or family use. While state-provided storage of all UCB for
personal use may, although extremely costly, satisfy social justice concerns, such a solution
may also threaten the real and symbolic value attached to altruistic donation of tissues and,
perhaps in the end, the very existence of public UCB banks.

Word count: 777

Source: https://www.mja.com.au/journal/2008/188/9/umbilical-cord-blood-banking-public-good-
or-private-benefit
 Reading C01

1. In the first paragraph, what does the phrase ‘these difficulties’ refer to?

A discovering cures for malignant and benign conditions

B differences between bone-marrow and UCB treatments
C finding a suitable related or non-related donor
D low numbers of both family and volunteer donors

2. In the first paragraph, we are told that the author’s main argument will be that

A private UCB banks have more social value than public UCB banks.
B both private and public UCB banks have a beneficial role in society.
C advances in stem cell therapies will impact private and public UCB banks.
D public UCB banks have a valid purpose but private UCB banks do not.

3. In the second paragraph, the word ‘analogous’ suggests that public UCB banks and
bone marrow donor registries are

A different.
B comparable.
C helpful.
D connected.

4. The author suggests that public UCB banks in Australia

A provide a satisfactory resource for transplant patients.

B are in direct competition with transplant centres.
C face significant challenges that make them ineffective.
D require greater public support and gifts of money.

5. According to the author, why will it be challenging to improve the ethnic diversity of
stocks at public UCB banks?

A Certain ethnic groups are reluctant to donate their UCB.

B Governments are unlikely to provide sufficient funds.
C It will be hard to achieve fair outcomes for everyone.
D Recruiting staff for regional centres will be difficult.
 Reading C01

6. Regarding the three assumptions that underlie private UCB banking, the author

A explains why none of them is valid.

B states that further research is required.
C questions the evidence used to support them.
D uses statistical data to support them.

7. What is the author’s attitude towards the future use of UCB stem cells?

A optimistic about the many possible uses

B cautious about issues of fairness
C dismissive of the long term relevance
D confident about research outcomes

8. What concern does the author express about publicly-funded storage of UCB for
personal use?

A It creates problems with regard to equality.

B People will no longer see the benefits of donating tissues.
C The costs may outweigh the benefits.
D It could cause both public and private UCB banks to close.
 The pandemic challenge

Over recent decades, thanks to better vaccines and strategic interventions, the world has seen
incredible progress in reducing child mortality and tackling infectious diseases. Yet there is one area
where the world isn’t making much progress and that is pandemic preparedness, but it is no less
important. This failure should concern the entire international community, because history has
taught us that there will undoubtedly be another deadly worldwide pandemic. There is no way of
predicting when, but given the continual emergence of new pathogens, the increasing risk of a
bioterror attack, and the ever-increasing connectedness of our world, there is a significant
probability that a large and lethal modern-day pandemic will occur in our lifetime.

Several events in the past decade have warranted close attention to the risk of future pandemics.
One was the outbreak of swine flu (H1N1) in 2009. Although H1N1 influenza wasn’t as lethal as
people initially feared, it called attention to our inability to track the spread of disease, and the need
to develop new tools for public-health emergencies. The more recent outbreaks of Ebola in Africa
were another wake-up call. As the number of confirmed cases climbed, the death toll mounted, and
health systems local to the outbreak collapsed. Again, the world was much too slow to respond.
What the world needs is a coordinated global approach to pandemics that will work regardless of
whether the next pandemic is a product of human intervention or of nature itself.

The 1918 influenza epidemic killed an estimated fifty million people. Today, many countries have
life-saving interventions that weren’t available at that time, such as the seasonal influenza vaccine.
Although, this isn’t always fully effective, and must be taken each year, it represents an enormous
step forward. There are also now antibiotics that help with secondary infections from bacterial
pneumonia. Yet despite such advances, a simulation by the Institute for Disease Modelling shows
what would happen if a highly contagious and lethal airborne pathogen, like the 1918 influenza,
were to appear today. Nearly thirty-three million people worldwide would die in just six months.
The next threat, however, may not be influenza at all. It may well be an unknown pathogen seen for
the first time during an outbreak, as was the case with SARS (severe acute respiratory syndrome),
MERS (Middle East respiratory syndrome), and other recently found infectious diseases. The world
took a step to begin addressing this risk with the launch in 2017 of a public–private partnership
called the Coalition for Epidemic Preparedness Innovations (CEPI). With funding commitments of
more than US$630 million, CEPI’s first job is advancing the development of vaccines for three of the
priority diseases on the World Health Organization (WHO) list for public health research and
development: Lassa fever, Nipah virus, and MERS.

CEPI will also be working on rapid-response platforms to produce safe, effective vaccines for a range
of infectious diseases. Later this year, the coalition will announce grants to several companies,
working with a variety of technologies, including nucleic acid vaccines, viral vectors, and other
innovative approaches. The goal is the capability to develop, test, and release new vaccines in a
matter of months rather than years. But vaccines can’t be the only answer when immediate
response is vital to a rapidly spreading infectious disease. Not only do vaccines take time to develop
and deploy, they also take at least a couple of weeks after vaccination to generate protective
immunity. So investment is needed in other approaches, such as antiviral drugs and antibody
therapies that can be stockpiled or rapidly manufactured to stop the spread of pandemic diseases or
to treat people who have been exposed.

At a recent international security conference, world leaders were asked to imagine that somewhere
in the world a new weapon exists or could emerge that is capable of killing millions of people,
bringing economies to a standstill, and casting nations into chaos. If it were a military weapon, the
response would be to do everything possible to develop countermeasures. In the case of biologic
threats, that sense of urgency is sadly lacking. But the world needs to prepare for pandemics in the
same serious way it prepares for war. This preparation includes staging simulations, war games, and
preparedness exercises to increase understanding of how diseases will spread and how to deal with
responses such as quarantine and communications to minimise panic. Such a clear road map for a
comprehensive pandemic preparedness and response system is imperative, because lives, in
numbers too great to comprehend, depend on it.

(758 words)

https://www.nejm.org/doi/full/10.1056/NEJMp1806283
1. In the first paragraph, the writer says that preparation for pandemics should

○
A be designed to reduce their impact.

○
B be more widely recognised as a priority.

○
C take account of their increasing frequency.

○
D take precedence over other medical programmes.

2. The H1N1 influenza outbreak revealed a weakness in our ability to

○
A monitor the extent of an epidemic as it grows.

○
B predict the speed at which epidemics can develop.

○
C support local health systems at the height of an epidemic.

○
D mobilise additional resources in areas affected by an epidemic.

3. The writer uses statistical information in the third paragraph to

○
A demonstrate that technology improves over time.

○
B show the consequences of not learning from history.

○
C stress present-day vulnerability to infectious diseases.

○
D underline the efficiency of current vaccines and antibiotics.

4. In the fourth paragraph, what is suggested about unknown pathogens?

○
A They pose a greater threat than influenza.

○
B They are being discovered at an alarming rate.

○
C Financial resources are being committed to predicting them.

○
D Commercial interests are contributing to efforts to combat them.
5. In the fourth paragraph, what do the words ‘this risk’ refer to?

○
A an outbreak of a disease which was not previously known to exist.

○
B an increase in the total number of recognised infectious diseases.

○
C the cost of developing vaccines for newly discovered pathogens.

○
D the danger posed by diseases on the WHO priority list.

6. In the fifth paragraph, the writer says that vaccinations against infectious diseases

○
A represent a fast-acting means of protecting the public.

○
B are the most cost effective way of responding to them.

○
C attract a disproportionate amount of available funding.

○
D need to be complemented by a range of other measures.

7. In the final paragraph, the writer expresses regret that

○
A biologic threats aren’t taken more seriously.

○
B a pandemic may one day be used as a form of weapon.

○
C world leaders are reluctant to discuss pressing medical issues.

○
D military spending has priority over investment in medical resources.

8. The expression ‘road map’ in the final paragraph refers to

○
A a series of simulation activities.

○
B a set of detailed plans and objectives.

○
C a training package for use with medical staff.

○
D a way of organising channels of communication.