NMC-CBT Physiological Observations and Escalation Flashcards

A patient's National Early Warning Score (NEWS2) is 7. According to the standard protocol, which level of response is required?

Answer: Emergency response — immediate review

A NEWS2 score of 7 or above triggers an emergency response with immediate review by a clinician competent in managing acute illness.

Which of the following best describes the AVPU scale used in neurological assessment?

Answer: Alert, Verbal, Pain, Unresponsive

AVPU assesses consciousness level as Alert, responding to Voice, responding to Pain, or Unresponsive.

A patient's temperature is 38.8°C and they are shivering. Which condition should the nurse FIRST consider?

Answer: Infection or sepsis

Fever with rigors is a classic presentation of infection and should prompt assessment for sepsis using a structured tool.

When using the SBAR communication tool, what does the 'A' stand for?

Answer: Assessment

SBAR stands for Situation, Background, Assessment, and Recommendation — a structured handover communication framework.

A postoperative patient's wound dressing is saturated with bright red blood 2 hours after surgery. What is the FIRST action?

Answer: Apply firm pressure and escalate to the surgical team immediately

Bright red haemorrhage suggests active bleeding; direct pressure and urgent escalation are the priority before further assessment.

Which capillary refill time is considered ABNORMAL in adults and should prompt further assessment?

Answer: More than 3 seconds

A capillary refill time greater than 3 seconds suggests impaired peripheral perfusion and warrants clinical escalation.

A patient on a continuous morphine infusion has a respiratory rate of 8 breaths per minute and a GCS of 10. Which drug is MOST likely required urgently?

Answer: Naloxone

Naloxone is the opioid antagonist used to reverse respiratory depression caused by morphine overdose.