NCNZ Patient Assessment

Question 1

Which systematic framework is commonly used by NZ nurses to communicate patient deterioration to the medical team?

Accepted Answer

SBAR (Situation, Background, Assessment, Recommendation)

Answer

SOAP (Subjective, Objective, Assessment, Plan)

Answer

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

Answer

ISBAR (Identify, Situation, Background, Assessment, Recommendation)

Question 2

Which vital sign parameter, when added to the NEWS2 (National Early Warning Score 2), specifically addresses sepsis risk?

Accepted Answer

New confusion or altered mental state

Answer

Respiratory rate

Answer

Temperature

Answer

Oxygen saturation

Question 3

A patient's SpO2 drops to 90% on room air. What is the most appropriate initial nursing action?

Accepted Answer

Apply supplemental oxygen and escalate to the medical team using SBAR/ISBAR

Answer

Document the finding and continue monitoring without intervention

Answer

Increase the patient's IV fluid rate

Answer

Administer PRN analgesia

Question 4

When completing a pain assessment for an adult patient who is unable to self-report pain, which tool is most appropriate?

Accepted Answer

Behavioural Pain Scale (BPS) or Critical Care Pain Observation Tool (CPOT)

Answer

Numeric Rating Scale (NRS) 0–10

Answer

Visual Analogue Scale (VAS)

Answer

Wong-Baker FACES scale

Question 5

Which of the following is the correct interpretation of a 12-lead ECG finding: P waves present, regular rhythm, rate 90 bpm, PR interval 0.14 s, QRS 0.08 s?

Accepted Answer

Normal sinus rhythm

Answer

First-degree heart block

Answer

Atrial fibrillation

Answer

Ventricular tachycardia

Question 6

A patient is admitted after a fall. On assessment, the nurse notices bruising at different stages of healing and a pattern inconsistent with the reported mechanism. What should the nurse do?

Accepted Answer

Document the findings thoroughly, report to the nurse in charge, and follow the organisation's safeguarding or elder abuse protocol

Answer

Ignore it as it is not a nursing concern

Answer

Ask the patient's family member (who accompanied them) what happened

Answer

Confront the suspected abuser directly