FREE NMC-CBT Physiological Observations and Escalation Questions and Answers

Question 1

A patient's physiological observations calculate to a National Early Warning Score (NEWS2) of 8. According to standard UK protocol, what is the required level of response?

Accepted Answer

An urgent response is required from a doctor or critical care outreach team.

Answer

Continue routine 4-hourly observations.

Answer

Inform the nurse in charge who will decide on the next steps.

Answer

Increase observations to hourly and inform the doctor at the next ward round.

Question 2

You are assessing a patient for suspected sepsis. Which combination of signs is most indicative of sepsis with organ dysfunction (severe sepsis)?

Accepted Answer

High respiratory rate, low blood pressure, and new confusion.

Answer

Low grade fever, normal heart rate, and clear speech.

Answer

Normal temperature, high blood pressure, and a rash.

Answer

Low urine output, slow capillary refill, and normal respiratory rate.

Question 3

Why is an accurate measurement of a patient's respiratory rate considered a crucial part of routine observations?

Accepted Answer

It is often the earliest and most sensitive indicator of clinical deterioration.

Answer

It is the best indicator of a patient's cardiac function.

Answer

It is only important in patients with a known respiratory condition.

Answer

It is easy to measure and less important than blood pressure.

Question 4

When escalating concerns about a deteriorating patient to a doctor, which communication tool is recommended to ensure information is conveyed clearly and concisely?

Accepted Answer

SBAR (Situation, Background, Assessment, Recommendation)

Answer

SOAP (Subjective, Objective, Assessment, Plan)

Answer

NEWS2 (National Early Warning Score 2)

Answer

ABCDE (Airway, Breathing, Circulation, Disability, Exposure)

Question 5

A nurse is assessing a patient's level of consciousness. The patient only opens their eyes and moans in response to a painful stimulus (trapezius squeeze). How would this be recorded using the AVPU scale?

Accepted Answer

P (Pain)

Answer

A (Alert)

Answer

V (Voice)

Answer

U (Unresponsive)

Question 6

Using a blood pressure cuff that is too small for a patient's arm is most likely to result in what kind of reading?

Accepted Answer

A falsely high reading

Answer

A falsely low reading

Answer

An accurate reading

Answer

An inability to obtain a reading