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Patient Assessment & NEWS2 Flashcards

6 cards from real NMC OSCE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.

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  1. When performing a head-to-toe patient assessment, which system should be assessed first if the patient appears acutely unwell?

    Answer: Airway, Breathing, Circulation using the ABCDE approach

    In any acutely unwell patient, the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is used. This systematic method prioritises life-threatening problems by assessing and treating in order of urgency.

  2. A patient's blood pressure is recorded as 88/56 mmHg and they have a respiratory rate of 26 breaths per minute. What is the most appropriate immediate action?

    Answer: Escalate immediately to the medical team and apply ABCDE approach

    Hypotension (systolic 20 breaths/min) are red flag signs suggesting haemodynamic instability or sepsis. Immediate escalation using a structured communication tool (e.g., SBAR) and the ABCDE approach is essential.

  3. What does SBAR stand for in the context of clinical communication?

    Answer: Situation, Background, Assessment, Recommendation

    SBAR stands for Situation, Background, Assessment, Recommendation. It is a structured communication tool widely used in the NHS to ensure safe, efficient handover of clinical information, particularly during escalation of deteriorating patients.

  4. During patient assessment, a nurse notes that a patient is using accessory muscles to breathe. What does this indicate?

    Answer: Increased work of breathing suggesting respiratory distress

    Use of accessory muscles (sternocleidomastoid, scalenes, intercostals) during breathing indicates increased work of breathing, a sign of respiratory distress. It suggests the diaphragm and primary respiratory muscles are not meeting ventilatory demands.

  5. A patient's capillary refill time is measured at 4 seconds. What does this indicate?

    Answer: Possible peripheral vasoconstriction or poor perfusion

    Normal capillary refill time is less than 2 seconds. A CRT of 4 seconds suggests peripheral vasoconstriction or poor perfusion, which may indicate shock, hypothermia, or peripheral vascular disease. It should be interpreted alongside other perfusion markers.

  6. Which GCS score indicates a severe brain injury?

    Answer: GCS 8 or below

    The Glasgow Coma Scale (GCS) ranges from 3 (no response) to 15 (fully alert). A GCS of 8 or below indicates severe brain injury and typically necessitates airway protection, often with intubation. Moderate injury is 9–12 and mild is 13–15.