NMC-CBT Physiological Observations and Escalation Flashcards
6 cards from real NMC CBT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 NMC-CBT Physiological Observations and Escalation flashcards as text
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?
Answer: An urgent response is required from a doctor or critical care outreach team.
A NEWS2 score of 7 or more indicates a high level of clinical risk and the potential for critical illness. This requires an urgent response from a team with critical care skills, such as a doctor or a critical care outreach team, for immediate assessment and intervention.
You are assessing a patient for suspected sepsis. Which combination of signs is most indicative of sepsis with organ dysfunction (severe sepsis)?
Answer: High respiratory rate, low blood pressure, and new confusion.
The combination of a high respiratory rate (tachypnoea), low blood pressure (hypotension), and an altered mental state are key red flag signs for sepsis. These indicate the body's systemic inflammatory response is causing organ dysfunction.
Why is an accurate measurement of a patient's respiratory rate considered a crucial part of routine observations?
Answer: It is often the earliest and most sensitive indicator of clinical deterioration.
An increased respiratory rate (tachypnoea) is a sensitive but non-specific sign of illness. It is often the very first indicator that a patient is deteriorating, as the body tries to compensate for problems like hypoxia or metabolic acidosis.
When escalating concerns about a deteriorating patient to a doctor, which communication tool is recommended to ensure information is conveyed clearly and concisely?
Answer: SBAR (Situation, Background, Assessment, Recommendation)
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool widely used in healthcare. It ensures that information is passed between clinicians in a clear, concise, and structured way, reducing the risk of miscommunication.
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?
Answer: P (Pain)
The AVPU scale assesses consciousness: Alert, Voice, Pain, Unresponsive. Since the patient only responds to a painful stimulus, the correct recording is 'P' for Pain.
Using a blood pressure cuff that is too small for a patient's arm is most likely to result in what kind of reading?
Answer: A falsely high reading
A cuff that is too small will not compress the brachial artery evenly and will require more pressure to occlude it. This leads to a falsely high blood pressure reading, which could result in unnecessary medical treatment.