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
A patient who was alert on morning rounds is now responding only to voice 4 hours later. What change in GCS components does this MOST likely reflect?
Answer: Deterioration in level of consciousness requiring urgent review
Any decline in consciousness level is a red flag sign of deterioration requiring urgent clinical assessment regardless of exact GCS figure.
Which of the following is a sign of a TENSION pneumothorax that requires immediate escalation?
Answer: Tracheal deviation away from the affected side with hypotension
Tracheal deviation away from the affected side with cardiovascular collapse indicates tension pneumothorax — a life-threatening emergency.
A patient tells a nurse they feel like they are going to die and appear pale and clammy. Their BP is 85/50 and HR is 130. The nurse should FIRST:
Answer: Activate the emergency response team immediately
Profound hypotension with tachycardia and clinical distress indicates haemodynamic shock requiring an immediate emergency response.
When performing a manual blood pressure measurement, the nurse should place the stethoscope diaphragm over which artery?
Answer: Brachial artery
Korotkoff sounds are auscultated over the brachial artery in the antecubital fossa to determine systolic and diastolic pressure.
A patient receiving IV gentamicin develops a new creatinine rise of 30% from baseline. Which physiological concern does this PRIMARILY raise?
Answer: Aminoglycoside-induced nephrotoxicity
Gentamicin is nephrotoxic; a rising creatinine indicates acute kidney injury and requires dose review and medical escalation.
A patient's temperature drops to 35.1°C following major abdominal surgery. Which intervention is the FIRST priority?
Answer: Initiate active warming measures and escalate to the surgical team
Post-operative hypothermia impairs coagulation and wound healing; active warming and medical review are required promptly.
Which element of the Sepsis Six bundle should be completed within the FIRST HOUR of sepsis recognition?
Answer: Take blood cultures before starting antibiotics
Blood cultures must be taken before antibiotic administration to guide sensitivities, but antibiotics should not be delayed beyond 1 hour.