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

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?

Accepted Answer

New confusion or altered mental state

Answer

The NEWS2 scoring system includes new confusion/altered consciousness (scored as 3 — 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?

Accepted Answer

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

Answer

An SpO2 of 90% is below the normal range (95–100%) 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?

Accepted Answer

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

Answer

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?

Accepted Answer

Normal sinus rhythm

Answer

This ECG describes normal sinus rhythm: P waves present before each QRS, regular rhythm, rate 60–100 bpm, normal PR interval (0.12–0.20 s), and normal QRS duration (<0.12 s). All parameters are within normal limits.

NCNZ Practice Test

NCNZ Practice Test

NCNZ Patient Assessment