NCNZ Patient Assessment β Questions and Answers
Question 1: Which systematic framework is commonly used by NZ nurses to communicate patient deterioration to the medical team?
- SBAR (Situation, Background, Assessment, Recommendation) (Correct answer)
- SOAP (Subjective, Objective, Assessment, Plan)
- ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
- ISBAR (Identify, Situation, Background, Assessment, Recommendation)
Correct answer: SBAR (Situation, Background, Assessment, Recommendation)
SBAR (or ISBAR including Identify) is the recommended communication tool for escalating patient deterioration in NZ healthcare settings, providing a structured, efficient handover that reduces communication failures.
Question 2: Which vital sign parameter, when added to the NEWS2 (National Early Warning Score 2), specifically addresses sepsis risk?
- New confusion or altered mental state (Correct answer)
- Respiratory rate
- Temperature
- Oxygen saturation
Correct answer: New confusion or altered mental state
The NEWS2 scoring system includes new confusion/altered consciousness (scored as 3 β the highest possible for a single parameter) as an acute indicator of potential sepsis, organ dysfunction, or neurological deterioration.
Question 3: A patient's SpO2 drops to 90% on room air. What is the most appropriate initial nursing action?
- Apply supplemental oxygen and escalate to the medical team using SBAR/ISBAR (Correct answer)
- Document the finding and continue monitoring without intervention
- Increase the patient's IV fluid rate
- Administer PRN analgesia
Correct answer: Apply supplemental oxygen and escalate to the medical team using SBAR/ISBAR
An SpO2 of 90% is below the normal range (95β100%) and indicates hypoxaemia. The nurse should apply supplemental oxygen, reassess, and escalate to the medical team promptly. Oxygen therapy should be titrated to target saturation.
Question 4: When completing a pain assessment for an adult patient who is unable to self-report pain, which tool is most appropriate?
- Behavioural Pain Scale (BPS) or Critical Care Pain Observation Tool (CPOT) (Correct answer)
- Numeric Rating Scale (NRS) 0β10
- Visual Analogue Scale (VAS)
- Wong-Baker FACES scale
Correct answer: Behavioural Pain Scale (BPS) or Critical Care Pain Observation Tool (CPOT)
When patients cannot self-report (e.g., intubated, cognitively impaired), observational tools like the BPS or CPOT assess behavioural indicators of pain (facial expression, body movement, ventilator compliance). Self-report tools require the patient to communicate a number or point.
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?
- Normal sinus rhythm (Correct answer)
- First-degree heart block
- Atrial fibrillation
- Ventricular tachycardia
Correct answer: Normal sinus rhythm
This ECG describes normal sinus rhythm: P waves present before each QRS, regular rhythm, rate 60β100 bpm, normal PR interval (0.12β0.20 s), and normal QRS duration (<0.12 s). All parameters are within normal limits.
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?
- Document the findings thoroughly, report to the nurse in charge, and follow the organisation's safeguarding or elder abuse protocol (Correct answer)
- Ignore it as it is not a nursing concern
- Ask the patient's family member (who accompanied them) what happened
- Confront the suspected abuser directly
Correct answer: Document the findings thoroughly, report to the nurse in charge, and follow the organisation's safeguarding or elder abuse protocol
Inconsistent injuries with multi-stage bruising raise safeguarding concerns. The nurse must document accurately, escalate to the senior nurse, and follow the organisation's safeguarding protocol. In NZ, elder abuse and family violence require a structured response.
NCNZ Patient Assessment
Which systematic framework is commonly used by NZ nurses to communicate patient deterioration to the medical team?