NSE 203 Combined Exam
Study Set
observable evidence of vital sign instability & visible patient deterioration can occur
from ____ to _____ before cardiac arrest, and happens most frequently on ________ units -
Answer 6 to 24 hours
medical-surgical
what is clinical deterioration? - Answer a dynamic state experienced by a patient
compromising hemodynamic stability, marked by physiological decompensation
accompanied by subjective or objective findings
what does dynamic state mean? - Answer variations in physiological parameters
what is decompensation? - Answer inability to maintain homeostatic function
physiologically or psychologically
SATA: what are some negative outcomes related to clinical deterioration?
a) increased mortality
b) increased resuscitation
c) fewer codes
d) need for higher level of care
e) prolonged hospital admission - Answer a) increased mortality
b) increased resuscitation
d) need for higher level of care
e) prolonged hospital admission
T or F: when RR increases but then decreases to normal levels, it means the patient has
improved - Answer F: not necessarily - it could simply mean their body can't keep up
anymore
what are some common changes in vital signs that indicate clinical deterioration?
a) increased RR then decrease
b) increased pulse then decrease
c) decreased pulse then increase
,d) increase BP and then decreased
e) temperature rising
f) O2 sat slowly decline then rapidly after 88% - Answer a) increased RR then decrease
b) increased pulse then decrease
d) increase BP and then decreased
f) O2 sat slowly decline then rapidly after 88%
what are the three assessment tools used to recognize deterioration? - Answer ABCDE
(primary survey)
NEWS2
FAST
what does ABCDE stand for? - Answer Airway
Breathing
Circulation
Disability
Exposure
what steps are involved in "Airway"? (primary survey) - Answer assess airway patency
what steps are involved in "Breathing"? (primary survey) - Answer measure RR
evaluate WOB
measure O2 saturation
SATA: what steps are involved in "Breathing"? (primary survey)
a) measure RR
b) evaluate WOB
c) measure O2 saturation
e) assess skin colour changes
f) evaluate speech - Answer a) measure RR
b) evaluate WOB
c) measure O2 saturation
,what steps are involved in "Circulation"? (primary survey) - Answer palpate pulse rate &
rhythm
measure BP by auscultation
assess urine output
SATA: what steps are involved in "Circulation"? (primary survey)
a) palpate pulse rate & rhythm
b) assess colour changes
c) assess sensation changes
d) measure BP by auscultation
e) assess urine output - Answer a) palpate pulse rate & rhythm
d) measure BP by auscultation
e) assess urine output
what steps are involved in "Disability"? (primary survey) - Answer assess LOC
evaluate speech
assess for pain
assess for changes in facial & body symmetry, weakness, balance
assess for sudden changes in vision
SATA: what steps are involved in "Disability"? (primary survey)
a) assess LOC
b) inspect skin integrity
c) measure body temp
d) evaluate speech
e) assess for pain
f) assess for changes in facial & body symmetry, weakness, balance
g) assess for sudden changes in vision - Answer a) assess LOC
d) evaluate speech
e) assess for pain
, f) assess for changes in facial & body symmetry, weakness, balance
g) assess for sudden changes in vision
what steps are involved in "Exposure"? (primary survey) - Answer measure body
temperature
inspect skin integrity
inspect & palpate skin for signs of pressure injury
observe any wounds, dressings or drains, invasive lines
observe ability to transfer & mobilize
assess bowel movements
SATA: what steps are involved in "Exposure"? (primary survey)
a) measure body temperature
b) inspect skin integrity
c) inspect & palpate skin for signs of pressure injury
d) assess urine output
e) observe any wounds, dressings or drains, invasive lines
f) observe ability to transfer & mobilize
g) assess bowel movements - Answer a) measure body temperature
b) inspect skin integrity
c) inspect & palpate skin for signs of pressure injury
e) observe any wounds, dressings or drains, invasive lines
f) observe ability to transfer & mobilize
g) assess bowel movements
what signs are significantly associated with death?
a) partial airway obstruction
b) poor peripheral circulation
c) greater than expected drain fluid loss
d) decreased urine output
Study Set
observable evidence of vital sign instability & visible patient deterioration can occur
from ____ to _____ before cardiac arrest, and happens most frequently on ________ units -
Answer 6 to 24 hours
medical-surgical
what is clinical deterioration? - Answer a dynamic state experienced by a patient
compromising hemodynamic stability, marked by physiological decompensation
accompanied by subjective or objective findings
what does dynamic state mean? - Answer variations in physiological parameters
what is decompensation? - Answer inability to maintain homeostatic function
physiologically or psychologically
SATA: what are some negative outcomes related to clinical deterioration?
a) increased mortality
b) increased resuscitation
c) fewer codes
d) need for higher level of care
e) prolonged hospital admission - Answer a) increased mortality
b) increased resuscitation
d) need for higher level of care
e) prolonged hospital admission
T or F: when RR increases but then decreases to normal levels, it means the patient has
improved - Answer F: not necessarily - it could simply mean their body can't keep up
anymore
what are some common changes in vital signs that indicate clinical deterioration?
a) increased RR then decrease
b) increased pulse then decrease
c) decreased pulse then increase
,d) increase BP and then decreased
e) temperature rising
f) O2 sat slowly decline then rapidly after 88% - Answer a) increased RR then decrease
b) increased pulse then decrease
d) increase BP and then decreased
f) O2 sat slowly decline then rapidly after 88%
what are the three assessment tools used to recognize deterioration? - Answer ABCDE
(primary survey)
NEWS2
FAST
what does ABCDE stand for? - Answer Airway
Breathing
Circulation
Disability
Exposure
what steps are involved in "Airway"? (primary survey) - Answer assess airway patency
what steps are involved in "Breathing"? (primary survey) - Answer measure RR
evaluate WOB
measure O2 saturation
SATA: what steps are involved in "Breathing"? (primary survey)
a) measure RR
b) evaluate WOB
c) measure O2 saturation
e) assess skin colour changes
f) evaluate speech - Answer a) measure RR
b) evaluate WOB
c) measure O2 saturation
,what steps are involved in "Circulation"? (primary survey) - Answer palpate pulse rate &
rhythm
measure BP by auscultation
assess urine output
SATA: what steps are involved in "Circulation"? (primary survey)
a) palpate pulse rate & rhythm
b) assess colour changes
c) assess sensation changes
d) measure BP by auscultation
e) assess urine output - Answer a) palpate pulse rate & rhythm
d) measure BP by auscultation
e) assess urine output
what steps are involved in "Disability"? (primary survey) - Answer assess LOC
evaluate speech
assess for pain
assess for changes in facial & body symmetry, weakness, balance
assess for sudden changes in vision
SATA: what steps are involved in "Disability"? (primary survey)
a) assess LOC
b) inspect skin integrity
c) measure body temp
d) evaluate speech
e) assess for pain
f) assess for changes in facial & body symmetry, weakness, balance
g) assess for sudden changes in vision - Answer a) assess LOC
d) evaluate speech
e) assess for pain
, f) assess for changes in facial & body symmetry, weakness, balance
g) assess for sudden changes in vision
what steps are involved in "Exposure"? (primary survey) - Answer measure body
temperature
inspect skin integrity
inspect & palpate skin for signs of pressure injury
observe any wounds, dressings or drains, invasive lines
observe ability to transfer & mobilize
assess bowel movements
SATA: what steps are involved in "Exposure"? (primary survey)
a) measure body temperature
b) inspect skin integrity
c) inspect & palpate skin for signs of pressure injury
d) assess urine output
e) observe any wounds, dressings or drains, invasive lines
f) observe ability to transfer & mobilize
g) assess bowel movements - Answer a) measure body temperature
b) inspect skin integrity
c) inspect & palpate skin for signs of pressure injury
e) observe any wounds, dressings or drains, invasive lines
f) observe ability to transfer & mobilize
g) assess bowel movements
what signs are significantly associated with death?
a) partial airway obstruction
b) poor peripheral circulation
c) greater than expected drain fluid loss
d) decreased urine output
