NMC CBT Nursing Practice and Decision Making 2 — Questions and Answers
Question 1: A nurse uses the Waterlow tool. Which factors does it consider?
- Only age and weight
- Build/BMI, skin type, mobility, continence, appetite, and special risks including tissue malnutrition and neurological deficit (Correct answer)
- Only mobility and nutrition
- Blood pressure, heart rate, and respiratory rate
Correct answer: Build/BMI, skin type, mobility, continence, appetite, and special risks including tissue malnutrition and neurological deficit
The Waterlow score comprehensively assesses build/BMI, skin type, sex/age, mobility, continence, appetite, and special risk categories.
Waterlow assesses: build/BMI; visual skin assessment; sex/age; continence; mobility; appetite. Special risks: tissue malnutrition (cachexia, cardiac failure, PVD, anaemia); neurological deficit (diabetes, MS, stroke); surgery/trauma; medication (steroids, cytotoxics). Scores: 10+ = at risk; 15+ = high; 20+ = very high.
Question 2: What are the four stages of the nursing process?
- Diagnosis, treatment, monitoring, discharge
- Assessment, planning, implementation, evaluation (Correct answer)
- History, examination, investigation, management
- Admission, intervention, reassessment, transfer
Correct answer: Assessment, planning, implementation, evaluation
Assessment, Planning, Implementation, and Evaluation form the systematic nursing process.
The nursing process: (1) Assessment (subjective and objective data); (2) Planning (SMART goals and interventions); (3) Implementation (delivering care, documentation); (4) Evaluation (goal review, care plan modification). It is cyclical and supported by nursing models such as Roper-Logan-Tierney.
Question 3: Which are the classic signs of wound infection?
- Pallor, coolness, and dry wound edges
- Erythema, warmth, swelling, pain, and purulent discharge (Correct answer)
- Bruising and haematoma only
- Reduced sensation and numbness
Correct answer: Erythema, warmth, swelling, pain, and purulent discharge
Based on the cardinal signs of inflammation: redness, warmth, swelling, pain, plus purulent discharge. Systemic signs include pyrexia.
SSI signs: rubor (redness), calor (heat), tumor (swelling), dolor (pain — increasing rather than decreasing), functio laesa (loss of function), plus purulent/malodorous discharge, dehiscence, cellulitis, pyrexia, raised CRP/WCC. Management: wound swab for C&S, appropriate dressing, antimicrobials, nutrition, surgical team escalation.
Question 4: A patient has been NBM for 12 hours before surgery with dry mucous membranes. What is the appropriate nursing action?
- Continue NBM without intervention
- Provide mouth care, assess hydration, and contact surgical team to clarify fasting guidelines (Correct answer)
- Give sips of water without checking
- Commence IV fluids without prescription
Correct answer: Provide mouth care, assess hydration, and contact surgical team to clarify fasting guidelines
Current guidelines recommend clear fluids up to 2 hours before anaesthesia. A 12-hour fast exceeds guidelines. Provide mouth care and contact the surgical team.
Current Royal College of Anaesthetists guidelines: clear fluids up to 2 hours before; light meal up to 6 hours. A 12-hour fast risks dehydration, hypoglycaemia, and electrolyte imbalance. Nursing actions: mouth care; assess hydration; document concerns; contact surgical team; consider IV fluids (needs prescription); advocate for the patient.
Question 5: A patient with BMI 16 is admitted. Using MUST, what does the BMI score contribute?
- 0 points — within normal range
- 1 point — medium risk
- 2 points — high risk of malnutrition (Correct answer)
- 3 points — requires immediate enteral feeding
Correct answer: 2 points — high risk of malnutrition
In MUST, a BMI <18.5 scores 2 points (high risk). A BMI of 16 is significantly underweight.
MUST Step 1 (BMI): >20 = 0; 18.5-20 = 1; <18.5 = 2. Step 2 (weight loss in 3-6 months): <5% = 0; 5-10% = 1; >10% = 2. Step 3 (acute disease >5 days no intake = 2). Combined: 0 = low risk; 1 = medium (observe); 2+ = high risk (dietitian referral, nutritional goals, supplements).
Question 6: A nurse observes redness, pain, and a palpable venous cord at a cannula site. What VIP score is this?
- VIP 1 — possible first sign, observe
- VIP 2 — early stage, consider re-siting
- VIP 3 — medium stage, re-site the cannula (Correct answer)
- VIP 4 — advanced, re-site and treat
Correct answer: VIP 3 — medium stage, re-site the cannula
Redness, pain, and a palpable venous cord indicate VIP score 3 (medium stage phlebitis). Re-site and consider treatment.
VIP scale: 0 = healthy (no signs); 1 = possible (slight pain OR redness, observe); 2 = early (two of: pain, erythema, swelling, re-site); 3 = medium (pain along pathway + erythema + palpable cord, re-site and treat); 4 = advanced (all signs + cord >1 inch + purulent drainage, re-site and treat); 5 = thrombophlebitis (all + pyrexia). Assess at least every shift.
NMC CBT Nursing Practice and Decision Making 2
A nurse uses the Waterlow tool.
Which factors does it consider?