HNN 325 Exam UPDATED QUESTIONS
AND CORRECT ANSWERS
Clinical decision making - CORRECT ANSWER Problem-solving approach that nurses use to
define patient problems and select appropriate treatment.
-pattern recognition
-Critical thinking
-Evidence-based approaches
-Team work
-Sharing & reflection
Critical thinking - CORRECT ANSWER -The ability to weigh the importance of information
and discriminate between facts and guesses
-Noting similarities & differences then removing unnecessary information to help focus on the present
situation
-The RN's ability to process, experience and explore understanding of what you have done, why you
are doing it and the impact on yourself and others
Improving clinical decision-making skills - CORRECT ANSWER -Identify your knowledge
gaps & actively seek out help
-Trust your instincts
-Feel confident in asking questions to seek out the answers you need
-Clarify information as needed
-Consider the bigger picture & the patient in its entirety
-Have an open & inquisitive mind
Immediate life threatening - CORRECT ANSWER This is when you think the patients
condition is a threat to their life, or imminent risk of deterioration that requires immediate aggressive
intervention
-Experiencing respiratory or cardiac arrest and needs a code blue activated
-Immediate risk to airway eg. RR <10 or respiratory distress
-Profoundly hypotensive patient
GCS <9 or ongoing/ prolonged seizure
,Imminently life threatening - CORRECT ANSWER This is when you think the patient's
condition is serious enough or deteriorating so rapidly that there is a potential threat to life or organ
system failure. It also includes the need for important time-critical treatment or a patient experiencing
very severe pain.
-Required a MET call or has an airway risk
-Circulatory compromise, eg. Clammy skin, HR<50 or >150, severe blood loss or chest pain
-Suspected sepsis
-BGL<3
-GCS <13
-Fever with signs of lethargy
-Behavioural/ psychiatric eg. Violent or aggressive, immediate threat to self or others, requires or has
required restraints and severe agitation or aggression
Potentially life-threatening or situational urgency - CORRECT ANSWER This is when you
think the patient's condition may progress to life or limb-threatening, or may lead to significant
morbidity
-Moderate shortness of breath
-Seizure, but now alert
-Persistent vomiting
-Dehydration
-Moderately severe pain
-Behavioural/ psychiatric eg. Very distressed, risk of self-harm, agitated/ withdrawn potentially
aggressive
Potentially serious or situational urgency - CORRECT ANSWER This category is when the
patient's condition may deteriorate or adverse outcomes may occur if assessment and treatment are
delayed.
-Difficulty swallowing without respiratory distress
-Moderate pain
-Vomiting or diarrhoea
-Non-specific abdominal pain
Behavioural/ psychiatric eg. Under observation and/or no immediate risk to self or others
, Less urgent - CORRECT ANSWER This is when the patient's condition is chronic or minor
enough that symptoms or clinical outcome will not be significantly affected if assessment &
intervention is delayed
-Minimal pain
-Minor symptoms of existing stable illness
-Identified nursing assessments & interventions that are not time critical
Removal of sutures - Pre-procedure - CORRECT ANSWER -Introduce yourself to the patient,
explain & discuss the procedure with them and gain their consent to proceed
-Perform procedure using aseptic technique
Removal of sutures - Procedure - CORRECT ANSWER -Clean the wound with an appropriate
sterile solution, such as 0.9% sodium chloride, if required, if the incision line is under tension, use
free hand to gently support the skin either side of the surgical incision line
-Slide the lower bar of the clip remover with the V-shaped groove under the clip at an angle of 90˚.
Squeeze the handles of the clip remover together to open the clip
-Repeat until all clips have been removed
-Apply a suitable dressing
Removal of sutures - Post-procedure - CORRECT ANSWER -Dispose of waste in yellow
plastic clinical waste bags and sharps in a sharps bin.
-Remove gloves & wash hands
-Record the condition of the suture line & surrounding skin
This is important in case they deteriorate during your shift - CORRECT ANSWER Undertaking
a focused patient assessment should be completed at the beginning of your shift so that you can
identify any issues and have baseline patient information.
In what priority would you want to undertake the skills required for Mr Chol? - CORRECT
ANSWER 12 lead ECG, Cardiovascular assessment, Removal of staples
What rhythm is this? - CORRECT ANSWER sinus rhythm
AND CORRECT ANSWERS
Clinical decision making - CORRECT ANSWER Problem-solving approach that nurses use to
define patient problems and select appropriate treatment.
-pattern recognition
-Critical thinking
-Evidence-based approaches
-Team work
-Sharing & reflection
Critical thinking - CORRECT ANSWER -The ability to weigh the importance of information
and discriminate between facts and guesses
-Noting similarities & differences then removing unnecessary information to help focus on the present
situation
-The RN's ability to process, experience and explore understanding of what you have done, why you
are doing it and the impact on yourself and others
Improving clinical decision-making skills - CORRECT ANSWER -Identify your knowledge
gaps & actively seek out help
-Trust your instincts
-Feel confident in asking questions to seek out the answers you need
-Clarify information as needed
-Consider the bigger picture & the patient in its entirety
-Have an open & inquisitive mind
Immediate life threatening - CORRECT ANSWER This is when you think the patients
condition is a threat to their life, or imminent risk of deterioration that requires immediate aggressive
intervention
-Experiencing respiratory or cardiac arrest and needs a code blue activated
-Immediate risk to airway eg. RR <10 or respiratory distress
-Profoundly hypotensive patient
GCS <9 or ongoing/ prolonged seizure
,Imminently life threatening - CORRECT ANSWER This is when you think the patient's
condition is serious enough or deteriorating so rapidly that there is a potential threat to life or organ
system failure. It also includes the need for important time-critical treatment or a patient experiencing
very severe pain.
-Required a MET call or has an airway risk
-Circulatory compromise, eg. Clammy skin, HR<50 or >150, severe blood loss or chest pain
-Suspected sepsis
-BGL<3
-GCS <13
-Fever with signs of lethargy
-Behavioural/ psychiatric eg. Violent or aggressive, immediate threat to self or others, requires or has
required restraints and severe agitation or aggression
Potentially life-threatening or situational urgency - CORRECT ANSWER This is when you
think the patient's condition may progress to life or limb-threatening, or may lead to significant
morbidity
-Moderate shortness of breath
-Seizure, but now alert
-Persistent vomiting
-Dehydration
-Moderately severe pain
-Behavioural/ psychiatric eg. Very distressed, risk of self-harm, agitated/ withdrawn potentially
aggressive
Potentially serious or situational urgency - CORRECT ANSWER This category is when the
patient's condition may deteriorate or adverse outcomes may occur if assessment and treatment are
delayed.
-Difficulty swallowing without respiratory distress
-Moderate pain
-Vomiting or diarrhoea
-Non-specific abdominal pain
Behavioural/ psychiatric eg. Under observation and/or no immediate risk to self or others
, Less urgent - CORRECT ANSWER This is when the patient's condition is chronic or minor
enough that symptoms or clinical outcome will not be significantly affected if assessment &
intervention is delayed
-Minimal pain
-Minor symptoms of existing stable illness
-Identified nursing assessments & interventions that are not time critical
Removal of sutures - Pre-procedure - CORRECT ANSWER -Introduce yourself to the patient,
explain & discuss the procedure with them and gain their consent to proceed
-Perform procedure using aseptic technique
Removal of sutures - Procedure - CORRECT ANSWER -Clean the wound with an appropriate
sterile solution, such as 0.9% sodium chloride, if required, if the incision line is under tension, use
free hand to gently support the skin either side of the surgical incision line
-Slide the lower bar of the clip remover with the V-shaped groove under the clip at an angle of 90˚.
Squeeze the handles of the clip remover together to open the clip
-Repeat until all clips have been removed
-Apply a suitable dressing
Removal of sutures - Post-procedure - CORRECT ANSWER -Dispose of waste in yellow
plastic clinical waste bags and sharps in a sharps bin.
-Remove gloves & wash hands
-Record the condition of the suture line & surrounding skin
This is important in case they deteriorate during your shift - CORRECT ANSWER Undertaking
a focused patient assessment should be completed at the beginning of your shift so that you can
identify any issues and have baseline patient information.
In what priority would you want to undertake the skills required for Mr Chol? - CORRECT
ANSWER 12 lead ECG, Cardiovascular assessment, Removal of staples
What rhythm is this? - CORRECT ANSWER sinus rhythm
