NMC-CBT Physiological Observations and Escalation Flashcards
7 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 7 NMC-CBT Physiological Observations and Escalation flashcards as text
Which of the following blood glucose readings in a non-diabetic hospitalised patient requires immediate escalation?
Answer: 2.8 mmol/L
A blood glucose of 2.8 mmol/L indicates severe hypoglycaemia and requires immediate treatment and medical review.
A patient's pulse is 120 bpm, irregular, and their blood pressure has dropped from 130/80 to 90/60 mmHg over 20 minutes. What is the PRIORITY action?
Answer: Escalate to medical team immediately using SBAR
Tachycardia with haemodynamic compromise indicates potential shock or arrhythmia requiring immediate medical escalation via structured communication.
When documenting observations on a paper-based track and trigger chart, what should be done if a parameter cannot be measured?
Answer: Write 'N/A' and document the clinical reason
Documenting 'N/A' with a clinical reason maintains accurate records and avoids a falsely reassuring score.
A patient's pain score rises from 3/10 to 8/10 after physiotherapy. Their BP is 160/100 and HR is 104. Which action is MOST appropriate?
Answer: Assess the cause of pain, escalate to prescriber, and monitor vital signs
Acute severe pain causing autonomic physiological changes needs prompt assessment, pain management review, and monitoring.
Which oxygen saturation target is recommended for most acutely ill adult patients who are NOT at risk of hypercapnic respiratory failure?
Answer: 94–98%
For most acutely ill patients, an SpO2 of 94–98% is the standard target per BTS oxygen guidelines.
A nurse observes that a patient's urinary catheter bag has drained only 15 mL in the last 2 hours. The patient weighs 70 kg. What is the MOST appropriate response?
Answer: Assess for catheter obstruction, check fluid balance, and escalate if oliguria confirmed
Output of 15 mL/2 hrs (7.5 mL/hr) is below the 0.5 mL/kg/hr threshold; catheter patency and fluid status must be assessed before escalating.
During a NEWS2 assessment, a patient with no new oxygen requirement has an SpO2 of 95%. What score does this parameter contribute?
Answer: 1
In NEWS2 Scale 1 (no supplemental O2), an SpO2 of 95% scores 1 point.