NMC CBT NMC-CBT Physiological Observations and Escalation 2 — Questions and Answers
Question 1: A patient's Early Warning Score (EWS) increases from 2 to 5 within one hour. What is the MOST appropriate immediate action?
- Continue monitoring at the scheduled interval
- Inform the nurse in charge and increase monitoring frequency (Correct answer)
- Call a cardiac arrest immediately
- Administer oxygen without further assessment
Correct 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.
Question 2: Which of the following respiratory rates in an adult patient at rest should be considered ABNORMAL and require documentation?
- 14 breaths per minute
- 18 breaths per minute
- 24 breaths per minute (Correct answer)
- 16 breaths per minute
Correct answer: 24 breaths per minute
A respiratory rate above 20 breaths per minute in an adult is abnormal and scores on early warning systems.
Question 3: When measuring blood pressure manually, the cuff should be inflated to approximately how many mmHg above the point at which the radial pulse disappears?
- 10 mmHg
- 20 mmHg
- 30 mmHg (Correct answer)
- 40 mmHg
Correct answer: 30 mmHg
Inflating 30 mmHg above pulse disappearance ensures the brachial artery is fully occluded before slow deflation.
Question 4: A patient with COPD has an SpO2 of 82%. Which action is MOST appropriate?
- Apply high-flow oxygen at 15 L/min immediately
- Target SpO2 88–92% with controlled oxygen and escalate (Correct answer)
- Reassure the patient and recheck in one hour
- Document and continue current care plan
Correct 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.
Question 5: Which urine output threshold over 1 hour in an adult indicates oliguria and should trigger escalation?
- Less than 0.5 mL/kg/hour (Correct answer)
- Less than 1 mL/kg/hour
- Less than 2 mL/kg/hour
- Less than 30 mL total regardless of weight
Correct 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.
Question 6: 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?
- Routine medical review within 4 hours
- Immediate emergency response — activate rapid response team (Correct answer)
- Notify the ward doctor by message
- Increase fluid intake and reassess in 30 minutes
Correct answer: Immediate emergency response — activate rapid response team
Multiple high-scoring parameters alongside haemodynamic compromise indicate critical deterioration requiring immediate response.
Question 7: When recording a 12-lead ECG, which electrode placement marks V4?
- 4th intercostal space, right sternal border
- 5th intercostal space, mid-clavicular line (Correct answer)
- 5th intercostal space, anterior axillary line
- 4th intercostal space, left sternal border
Correct answer: 5th intercostal space, mid-clavicular line
V4 is placed at the 5th intercostal space in the mid-clavicular line on the left side.
NMC CBT NMC-CBT Physiological Observations and Escalation 2
A patient's Early Warning Score (EWS) increases from 2 to 5 within one hour.
What is the MOST appropriate immediate action?