NMC CBT NMC-CBT Physiological Observations and Escalation 5

Question 1

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?

Accepted Answer

Deterioration in level of consciousness requiring urgent review

Answer

Any decline in consciousness level is a red flag sign of deterioration requiring urgent clinical assessment regardless of exact GCS figure.

Question 2

Which of the following is a sign of a TENSION pneumothorax that requires immediate escalation?

Accepted Answer

Tracheal deviation away from the affected side with hypotension

Answer

Tracheal deviation away from the affected side with cardiovascular collapse indicates tension pneumothorax — a life-threatening emergency.

Question 3

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:

Accepted Answer

Activate the emergency response team immediately

Answer

Profound hypotension with tachycardia and clinical distress indicates haemodynamic shock requiring an immediate emergency response.

Question 4

When performing a manual blood pressure measurement, the nurse should place the stethoscope diaphragm over which artery?

Accepted Answer

Brachial artery

Answer

Korotkoff sounds are auscultated over the brachial artery in the antecubital fossa to determine systolic and diastolic pressure.

Question 5

A patient receiving IV gentamicin develops a new creatinine rise of 30% from baseline. Which physiological concern does this PRIMARILY raise?

Accepted Answer

Aminoglycoside-induced nephrotoxicity

Answer

Gentamicin is nephrotoxic; a rising creatinine indicates acute kidney injury and requires dose review and medical escalation.

(NMC CBT) Nursing and Midwifery Council Computer-Based Test Practice Test