NMC-CBT Physiological Observations and Escalation Flashcards

A patient's Early Warning Score (EWS) increases from 2 to 5 within one hour. What is the MOST appropriate immediate action?

Answer: Inform the nurse in charge and increase monitoring frequency

An EWS of 5 triggers an urgent clinical review; the nurse in charge must be informed and observations increased.

Which of the following respiratory rates in an adult patient at rest should be considered ABNORMAL and require documentation?

Answer: 24 breaths per minute

A respiratory rate above 20 breaths per minute in an adult is abnormal and scores on early warning systems.

When measuring blood pressure manually, the cuff should be inflated to approximately how many mmHg above the point at which the radial pulse disappears?

Answer: 30 mmHg

Inflating 30 mmHg above pulse disappearance ensures the brachial artery is fully occluded before slow deflation.

A patient with COPD has an SpO2 of 82%. Which action is MOST appropriate?

Answer: Target SpO2 88–92% with controlled oxygen and escalate

COPD patients risk hypercapnic drive suppression, so oxygen is titrated to 88–92% target and the clinical team alerted.

Which urine output threshold over 1 hour in an adult indicates oliguria and should trigger escalation?

Answer: Less than 0.5 mL/kg/hour

Oliguria is defined as urine output below 0.5 mL/kg/hour, which may indicate renal impairment or poor perfusion.

A patient becomes acutely confused, has a respiratory rate of 26, a systolic BP of 88 mmHg, and SpO2 of 91%. Which escalation pathway is MOST appropriate?

Answer: Immediate emergency response — activate rapid response team

Multiple high-scoring parameters alongside haemodynamic compromise indicate critical deterioration requiring immediate response.

When recording a 12-lead ECG, which electrode placement marks V4?

Answer: 5th intercostal space, mid-clavicular line

V4 is placed at the 5th intercostal space in the mid-clavicular line on the left side.