NSE 203 Final Review Questions With Correct Answers

NSE 203 Final Review Questions With
Correct Answers

clinical deterioration not promptly recognized can - CORRECT ANSWER✔✔-
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increase pt morbidity & mortality
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barrier to recognizing & responding to clinical deterioration stems from ... -
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CORRECT ANSWER✔✔-practice variations among HCP
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consequences of not recognizing patient deterioration - CORRECT ANSWER✔✔-
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increased mortality, resuscitation, implementation of higher lvl of care &
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prolonged hospital admission | |




What is part of an ABCDE assessment? - CORRECT ANSWER✔✔-1) airway
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2) breathing
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3) circulation
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4) disability
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5) environment & exposure
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priority things to look for in pt airway? - CORRECT ANSWER✔✔-- any blocked or
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threatened airways |




- pt LOC
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- abnormal respiratory assessment findings (ex; stridor)
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,if you suspect neurological trauma when assessing airway you ... - CORRECT
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ANSWER✔✔-start w/ triple airway maneuver!! | | | |




Triple airway manoeuvre - CORRECT ANSWER✔✔-chin lift, jaw thrust, patient
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oxygen


what does vital sign instability & visible patient deterioration tend to occur? -
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CORRECT ANSWER✔✔-in most pts from 6-24 hrs before cardiac arrest
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clinical deterioration - CORRECT ANSWER✔✔-patient compromising
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*hemodynamic stability, marked by physiological decompensation* accompanied
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by subjective or objective findings.
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dynamic state - CORRECT ANSWER✔✔-variations in physiological parameters
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decompensation - CORRECT ANSWER✔✔-inability to maintain homeostatic fxn | | | | | | | |


physiologically or psychologically | |




what are indicators of clinical deterioration - CORRECT ANSWER✔✔-- sudden
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and/or unstable changes in vital signs (RR, BP, HR, O2)
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- for expert nurses, their intuition helps them determine if a patient looks right
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- skin color changes
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- decreased LOC
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assessments to recognize deterioration - CORRECT ANSWER✔✔-ABCDE
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,NEWS2
FAST


signs during primary survey that are *significantly associated w/ death* ... -
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CORRECT ANSWER✔✔-- partial airway obstruction
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- poor peripheral circulation
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- greater than expected drain fluid loss
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- decreased UO
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- decreased GCS
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- abnormal RR
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- new pain
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- low O2sat & low BP
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- alteration in mentation
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NEWS2 aka - CORRECT ANSWER✔✔-national early warning score
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purpose of NEWS2 - CORRECT ANSWER✔✔-- improve detection of & response to
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clinical deterioration in patients w/ acute illness
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- provide *standardized approach* to care of deteriorating patient
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- clear communication
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- identify a *score* for urgent clinical response
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, what does the NEWS2 score mean? - CORRECT ANSWER✔✔-*a high NEWS2
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score* identifies a sick patient who is deteriorating & requires *urgent clinical
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review*


what does NEWS2 score evaluate? - CORRECT ANSWER✔✔-- RR
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- O2 Sat
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- systolic BP
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- HR
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- LOC or new confusion
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- temp
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what to do if NEWS score is greater or equal to 3 - CORRECT ANSWER✔✔-discuss
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w/ duty nurse/senior colleague, & complete a *sepsis screen for signs of
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infection*


what to do if NEWS score is greater or equal to 6 - CORRECT ANSWER✔✔-
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immediate discussion w/ ACT advanced practitioner or ACT dr
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NEW score 0-4, clinical risk & response - CORRECT ANSWER✔✔-low risk, ward-
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based response |




NEW score of 3, clinical risk & response - CORRECT ANSWER✔✔-low-medium,
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urgent ward-based response
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NEW score of 5-6, clinical risk & response - CORRECT ANSWER✔✔-medium, key
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threshold for urgent response | | |