NCNZ Patient Assessment 2

Question 1

Which assessment tool is recommended in NZ for identifying patients at risk of pressure injuries?

Accepted Answer

Braden Scale

Answer

The Braden Scale is the most widely validated and commonly used pressure injury risk assessment tool internationally and in NZ, assessing sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Question 2

A nurse assesses a patient 4 hours post-appendicectomy. The patient has a respiratory rate of 24/min, temperature 38.8°C, heart rate 112 bpm, and is confused. What does this most likely represent?

Accepted Answer

Systemic Inflammatory Response Syndrome (SIRS) / early sepsis — escalate immediately

Answer

Two or more SIRS criteria (RR >20, temp >38 or <36°C, HR >90, WBC abnormal) with suspected infection (post-operative setting) constitutes suspected sepsis. Confusion adds neurological deterioration. This requires immediate escalation under the sepsis six pathway.

Question 3

When performing a neurological assessment using the Glasgow Coma Scale, what is the maximum total score?

Accepted Answer

15

Answer

The GCS assesses three domains: Eye opening (1–4), Verbal response (1–5), and Motor response (1–6). Maximum total = 4 + 5 + 6 = 15 (fully conscious). Minimum = 3 (deep coma or death).

Question 4

Which of the following is most consistent with an early sign of respiratory compromise in an adult patient?

Accepted Answer

Increasing respiratory rate (tachypnoea)

Answer

Tachypnoea (increased respiratory rate) is typically the earliest sign of respiratory compromise, preceding cyanosis, hypoxaemia on pulse oximetry, and haemodynamic changes. It reflects the body's compensatory attempt to maintain oxygenation.

Question 5

When assessing fluid balance in a post-operative patient, which of the following is the most accurate method?

Accepted Answer

Strict hourly fluid balance chart recording all intake (IV, oral, feeds) and output (urine, drains, NG, stool, vomit)

Answer

Accurate fluid balance requires documenting all measured inputs (IV fluids, oral intake, enteral feeds) and outputs (urine, wound drains, nasogastric aspirate, vomit, stool) hourly in the acute post-operative period.

NCNZ Practice Test

NCNZ Practice Test

NCNZ Patient Assessment 2