NMC CBT NMC-CBT Physiological Observations and Escalation 3 — Questions and Answers
Question 1: A patient's National Early Warning Score (NEWS2) is 7. According to the standard protocol, which level of response is required?
- Routine scheduled assessment
- Urgent assessment by the ward team within 30 minutes
- Emergency response — immediate review (Correct answer)
- Increase monitoring only, no clinical review needed
Correct 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.
Question 2: Which of the following best describes the AVPU scale used in neurological assessment?
- Alert, Verbal, Pain, Unresponsive (Correct answer)
- Awake, Vocalising, Posturing, Unconscious
- Alert, Verbal, Pupils, Unresponsive
- Arousable, Vocal, Purposeful, Unconscious
Correct answer: Alert, Verbal, Pain, Unresponsive
AVPU assesses consciousness level as Alert, responding to Voice, responding to Pain, or Unresponsive.
Question 3: A patient's temperature is 38.8°C and they are shivering. Which condition should the nurse FIRST consider?
- Hypothermia
- Infection or sepsis (Correct answer)
- Heat stroke
- Malignant hyperthermia from anaesthetic agents
Correct answer: Infection or sepsis
Fever with rigors is a classic presentation of infection and should prompt assessment for sepsis using a structured tool.
Question 4: When using the SBAR communication tool, what does the 'A' stand for?
- Assessment (Correct answer)
- Action
- Advice
- Alert
Correct answer: Assessment
SBAR stands for Situation, Background, Assessment, and Recommendation — a structured handover communication framework.
Question 5: A postoperative patient's wound dressing is saturated with bright red blood 2 hours after surgery. What is the FIRST action?
- Apply a second dressing on top and continue monitoring
- Apply firm pressure and escalate to the surgical team immediately (Correct answer)
- Remove the dressing and inspect the wound
- Record the finding and await the scheduled ward round
Correct 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.
Question 6: Which capillary refill time is considered ABNORMAL in adults and should prompt further assessment?
- Less than 1 second
- 1–2 seconds
- 2–3 seconds
- More than 3 seconds (Correct answer)
Correct answer: More than 3 seconds
A capillary refill time greater than 3 seconds suggests impaired peripheral perfusion and warrants clinical escalation.
Question 7: 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?
- Flumazenil
- Naloxone (Correct answer)
- Atropine
- Adenosine
Correct answer: Naloxone
Naloxone is the opioid antagonist used to reverse respiratory depression caused by morphine overdose.
NMC CBT NMC-CBT Physiological Observations and Escalation 3
A patient's National Early Warning Score (NEWS2) is 7.
According to the standard protocol, which level of response is required?