Platform 3: Provide & Monitor Care

Using the NEWS2 system, which total score indicates that an urgent clinical review is needed?

• AOnly a total of 7 or more
• BA total of 3 or more across all parameters
• CA total of 5 or more, or a score of 3 in any single parameter✓
• DA total of 1 or more in any parameter

Answer: NEWS2 triggers an urgent response at a total of 5 or more, or a score of 3 in any one parameter; 7 or more is an emergency response. A total of 1 to 4 prompts a ward-based assessment of the frequency of monitoring.

Which respiratory rate is within the normal range for a resting adult?

• A8 breaths per minute
• B32 breaths per minute
• C26 breaths per minute
• D16 breaths per minute✓

Answer: A normal adult resting respiratory rate is 12 to 20 breaths per minute. Rates of 8 and below or 25 and above score 3 on NEWS2, and respiratory rate is often the earliest sign of deterioration.

A patient with diabetes is sweaty, shaky and confused, and their capillary blood glucose is 3.1 mmol/L. They can swallow safely. What is the first action?

• AGive 15 to 20 g of fast-acting carbohydrate, such as glucose tablets or a sugary drink, and recheck in 10 to 15 minutes✓
• BGive a slice of bread or a couple of biscuits as slow-release carbohydrate and recheck the glucose in an hour
• CWithhold all food and drink in case the patient needs treatment, and call the doctor to review them
• DGive the patient's usual insulin dose now, since the abnormal reading shows their diabetes is poorly controlled

Answer: A blood glucose below 4 mmol/L with symptoms is hypoglycaemia. A conscious patient who can swallow is given 15 to 20 g of fast-acting carbohydrate and rechecked after 10 to 15 minutes, followed by longer-acting carbohydrate once they recover. Insulin would lower the glucose further.

Which description matches a category 2 pressure ulcer?

• APartial-thickness skin loss with a shallow open wound or an intact or ruptured blister✓
• BFull-thickness tissue loss with exposed bone, tendon or muscle visible in the base of the wound
• CIntact skin with an area of non-blanching redness over a bony prominence such as the sacrum or heel
• DFull-thickness skin loss with visible subcutaneous fat but no bone or tendon

Answer: Category 2 is partial-thickness loss of dermis, seen as a shallow open ulcer or a blister. Category 1 is non-blanching redness with intact skin, category 3 is full-thickness loss with fat visible, and category 4 exposes bone, tendon or muscle.

What is the target oxygen saturation range for most acutely ill adults who are not at risk of hypercapnic respiratory failure?

• A88 to 92%
• B94 to 98%✓
• C98 to 100%
• D90 to 94%

Answer: British Thoracic Society guidance sets a target of 94 to 98% for most acutely ill adults. The lower range of 88 to 92% is for patients at risk of hypercapnic respiratory failure, such as some people with COPD.

When performing adult basic life support, what ratio of chest compressions to rescue breaths is used?

• A30 compressions to 2 breaths✓
• B5 compressions to 1 breath
• C15 compressions to 2 breaths
• D30 compressions to 1 breath

Answer: Resuscitation Council UK adult basic life support uses 30 compressions followed by 2 rescue breaths, at a rate of 100 to 120 compressions per minute and a depth of 5 to 6 cm. For a child, anyone trained in paediatric basic life support uses 15:2 after five initial rescue breaths; a rescuer not trained in paediatric BLS uses 30:2.

An adult is choking and cannot cough, speak or breathe. What should the nursing associate do?

• ALay the person flat and begin chest compressions immediately
• BGive up to five back blows, then up to five abdominal thrusts, and alternate them until the object clears✓
• CEncourage the person to keep coughing as hard as they can and wait for the airway to clear on its own
• DGive abdominal thrusts only, since back blows are ineffective in adults and waste time that the person does not have

Answer: For a severe obstruction (unable to cough effectively) the sequence is up to five back blows followed by up to five abdominal thrusts, repeated. Encouraging coughing applies only to a mild obstruction, and CPR begins only if the person becomes unresponsive.

An adult develops sudden facial swelling, widespread urticaria, wheeze and a falling blood pressure after an antibiotic. What is the first-line treatment?

• AHigh-flow oxygen alone until a doctor arrives to prescribe treatment
• BOral antihistamine and close observation of the patient for the next hour before any other treatment
• CIntramuscular adrenaline 500 micrograms into the outer thigh, and call for emergency help✓
• DIntravenous hydrocortisone as the first drug given

Answer: This is anaphylaxis. Resuscitation Council UK guidance is intramuscular adrenaline 500 micrograms (0.5 mL of 1 in 1,000) for adults into the anterolateral thigh, repeated after 5 minutes if needed, with an emergency call, oxygen and fluids. Antihistamines and steroids are not first-line treatments.

A patient on a ward has a temperature of 38.6°C, a heart rate of 118 and a respiratory rate of 24, and appears confused. What should the nursing associate suspect and do?

• AEncourage oral fluids and rest, since a raised temperature and a fast pulse are common in the first days after surgery and settle on their own
• BSuspect sepsis, escalate immediately using NEWS2 and the local sepsis pathway, and support senior staff to start treatment✓
• CRecord the observations and mention them at the next routine handover
• DGive paracetamol for the temperature, encourage rest and fluids, and recheck the full set of observations in four hours' time

Answer: Fever, tachycardia, tachypnoea and new confusion together are red flags for sepsis, where every hour of delay matters. The NEWS2 score would trigger an urgent response; the nursing associate escalates immediately so that the sepsis six can be started.

What is the safest way to deal with a used needle after an injection?

• APlace it straight into a sharps container without re-sheathing it✓
• BRe-sheath it carefully and dispose of it in the clinical waste bag
• CLeave it on the tray for a colleague to dispose of at the end of the round
• DBend the needle so that it cannot be reused before disposal

Answer: Needles are never re-sheathed, bent or broken; they go directly into a sharps container at the point of use. Re-sheathing is a leading cause of needlestick injuries.

Which of the 'rights' of medicines administration is being checked when a nursing associate confirms the patient's name and date of birth against the wristband and the prescription chart?

• ARight time
• BRight route
• CRight patient✓
• DRight documentation

Answer: Confirming identity with two identifiers against the wristband and the chart is the 'right patient' check. Right time, route and documentation are separate checks made against the prescription and the record.

A patient is being fed through a nasogastric tube. Before each feed, what is the recommended way to confirm the tube is in the stomach?

• AListen over the stomach with a stethoscope while pushing 20 mL of air down the tube and listening for a whoosh
• BAspirate gastric contents and check the pH is between 1 and 5.5 on pH indicator paper✓
• CFlush the tube with a small amount of water and see whether the patient tolerates it without coughing
• DCheck that the patient is able to speak and is not coughing

Answer: NHS patient safety guidance requires gastric aspirate with a pH of 5.5 or below as the first-line check, with an X-ray if that cannot be obtained. The 'whoosh test' with air is unreliable and is not an acceptable method.

Which observation would score highest on NEWS2 and most urgently need escalation?

• AA temperature of 37.4°C
• BA new onset of confusion in a patient who was previously alert✓
• CA regular heart rate of 85 beats per minute at rest on the ward
• DA systolic blood pressure of 125 mmHg that has been stable all day

Answer: New confusion scores 3 on the NEWS2 consciousness parameter (the 'C' in ACVPU), which on its own triggers an urgent review. The other observations are within their normal ranges and score 0.

A patient who has had a stroke has been assessed as having an unsafe swallow. What should the nursing associate do when the patient asks for a drink?

• AGive the drink they ask for, since refusing it would breach their autonomy
• BKeep them nil by mouth, explain why, and ensure the speech and language therapy plan is followed✓
• CGive small sips of water only, since water cannot cause harm if aspirated
• DGive thickened fluids on their own judgement to keep the patient hydrated

Answer: An unsafe swallow means anything given by mouth, including water, can be aspirated and cause pneumonia. The patient stays nil by mouth with hydration provided another way until the speech and language therapist's plan says otherwise; changes to consistency are not the nursing associate's decision to make alone.

A patient's NEWS2 chart shows a respiratory rate of 22, oxygen saturation of 95% on air, temperature 38.2°C, heart rate 96, systolic BP 112 and they are alert. Which parameter scores the most?

• ARespiratory rate of 22✓
• BHeart rate of 96
• CSystolic blood pressure of 112
• DOxygen saturation of 95%

Answer: A respiratory rate of 21 to 24 scores 2 on NEWS2. Saturation of 94 to 95% scores 1, heart rate 91 to 110 scores 1, and a systolic of 111 to 219 scores 0. The rising respiratory rate is the earliest and most sensitive sign of deterioration.

What is the recommended sequence for assessing a deteriorating patient?

• ACirculation, Airway, Breathing, Disability, Exposure
• BBreathing, Airway, Circulation, Exposure, Disability
• CAirway, Breathing, Circulation, Disability, Exposure✓
• DDisability, Exposure, Airway, Breathing, Circulation

Answer: The ABCDE approach assesses and treats the most immediately life-threatening problems first, in order: airway, breathing, circulation, disability (neurological state, including glucose) and exposure.

A patient on the ward is found unresponsive and not breathing normally. What should the nursing associate do FIRST?

• AMove the patient into the recovery position and observe
• BTake a full set of observations to confirm cardiac arrest
• CCheck the patient's blood glucose and pupils before doing anything else, in case it is a hypo
• DCall for help and the resuscitation team, then start chest compressions✓

Answer: An unresponsive patient who is not breathing normally is in cardiac arrest until proven otherwise: summon help (2222 in most UK hospitals) and begin CPR immediately. The recovery position is for an unresponsive patient who IS breathing normally.

Which sign in a patient with a plaster cast on the arm requires urgent escalation?

• ASlight swelling of the fingers that improves with elevation
• BThe cast feeling heavy after the first day
• CMild itching under the cast
• DIncreasing pain, numbness and pale or cold fingers✓

Answer: Increasing pain out of proportion, altered sensation and pale, cold or pulseless fingers suggest compromised circulation or compartment syndrome, which is an emergency. Itching and mild swelling that settles with elevation are expected.

A patient being fed via a percutaneous endoscopic gastrostomy (PEG) tube should be positioned how during and after feeding?

• AOn their left side with the head of the bed flat
• BStanding or walking around the ward during the feed to encourage it to move through the gut more quickly
• CLying flat with one pillow so that the feed passes through the tube more easily by gravity
• DSitting up at 30 to 45 degrees or more, and kept there for at least 30 minutes afterwards✓

Answer: Elevating the head of the bed to at least 30 degrees during and after enteral feeding reduces the risk of reflux and aspiration pneumonia. Lying flat is the position most associated with aspiration.

A patient who has been on bed rest for a week complains of a painful, swollen, warm calf on one side. What should the nursing associate suspect and do?

• ASuspect a cramp; massage the calf firmly to relieve it
• BSuspect cellulitis; clean the skin, apply a dressing and ask for antibiotics to be prescribed at the next round
• CSuspect a muscle strain from lying awkwardly; apply heat and encourage the patient to walk it off on the ward
• DSuspect a deep vein thrombosis; do not massage the leg, and escalate for urgent medical assessment✓

Answer: Unilateral calf pain, swelling and warmth after immobility are classic signs of DVT. Massage could dislodge a clot; the patient needs prompt assessment, a Wells score and imaging.

When taking a manual blood pressure, why is it important to use the correct cuff size?

• AA large cuff is only used for patients with a history of hypertension
• BA cuff that is too small gives a falsely high reading and one that is too large a falsely low reading✓
• CCuff size affects the pulse rate that is recorded alongside the blood pressure, since a tight cuff slows the pulse
• DA wrong-sized cuff will not inflate properly, so no reading is obtained

Answer: The cuff bladder should encircle about 80% of the arm; a small cuff over-reads and a large cuff under-reads, either of which can change the NEWS2 score and the clinical decision.