NURBN3023 LAB UPDATED QUESTIONS AND VERIFIED
ANSWERS
Core physiological Observations - CORRECT ANSWER✅✅✅RR
SaO2
BP
Pulse
Temp
Pain
LOC
Changes in core physiological observations that would constitute a MET - CORRECT
ANSWER✅✅✅RR >30 or <8
SaO2 <90
BP systolic >140 or <90
Pulse >140 or <50
Temp >39
Significant change in pain
Altered LOC
Other indicators outside the core physiological observations that could indicate deterioration - CORRECT
ANSWER✅✅✅Loss of bowel sounds
Decrease in urine output
No urine output
Chest pain
High or low BGL
Threatened airway
What assessment findings are incorporated into the ABCDE primary assessment - CORRECT
ANSWER✅✅✅A - assess airway for patency
,B - assess breathing by looking for bi-lateral chest wall movement, listening for breath sounds and
feeling for chest movement
C - assess patient for circulation by checking pulse, capillary refill, colour and warmth
D - assessing patients LOC using AVPU, GCS, PEARL and pain levels
E - exposing patient from head to toe to check if there are any other injuries
Situational Awareness Definitions
- Perception
- Comprehension
- Projection - CORRECT ANSWER✅✅✅Perception: how you view things
Comprehension: how you understand the meaning
Projection: how you use what you found in the future
Factors that affect situational awareness - CORRECT ANSWER✅✅✅Stress, time pressure,
distractions, culture, fatigue
Algorithms for DRSABCD - CORRECT ANSWER✅✅✅D - Dangers
R - Response (AVPU)
S - Send for help
A - Airway
B - Breathing
C - Commence CPR
D - Defib
Secondary Survey - CORRECT ANSWER✅✅✅F - full set of obs, fluids
G - give analgesia, do they need glucose?
H - head to toe examination, history
, Management of an airway for a semiconscious person - CORRECT ANSWER✅✅✅Head tilt/chin lift,
jaw thrust, nasopharyngeal airway
Management of an airway for an unconscious person - CORRECT ANSWER✅✅✅Head tilt/chin lift,
jaw thrust, oropharyngeal airway (guedel's)
Management of an airway for an conscious person with spinal precautions - CORRECT
ANSWER✅✅✅Jaw thrust to limit spinal movements
Differentiate head tilt/chin lift and jaw thrust - CORRECT ANSWER✅✅✅Head tilt/chin lift: use two
fingers to lift chin in an upwards direction and other hand to tilt forehead back
Jaw thrust: use to hands on either side of jaw and pull upwards extending jaw out. Used in spinal
precaution patients and paediatric patients
Pulse oximetry
Indications
Advantages
Disadvantages
Limitations for Respiratory Failure 1 and 2 - CORRECT ANSWER✅✅✅Indications: to measure oxygen
saturation in patients and when using oxygen therapy to monitor effect
Advantages: cheap, easy to use, relatively reliable, non invasive, immediate readings
Disadvantages: only measures oxygen, can by inaccurate when used with nail polish or if the pt is
shivering
Limitations for Respiratory Failure 1 and 2
- useful in resp failure 1 as this type of failure causes hypoxia.
- not useful in resp failure 2 as this type of failure causes hypoxia but also hypercapnia (high CO2)
Non-rebreather Mask
Indications
Nursing Considerations - CORRECT ANSWER✅✅✅Indications: short term use in acutely unwell or
deteriorating patients
ANSWERS
Core physiological Observations - CORRECT ANSWER✅✅✅RR
SaO2
BP
Pulse
Temp
Pain
LOC
Changes in core physiological observations that would constitute a MET - CORRECT
ANSWER✅✅✅RR >30 or <8
SaO2 <90
BP systolic >140 or <90
Pulse >140 or <50
Temp >39
Significant change in pain
Altered LOC
Other indicators outside the core physiological observations that could indicate deterioration - CORRECT
ANSWER✅✅✅Loss of bowel sounds
Decrease in urine output
No urine output
Chest pain
High or low BGL
Threatened airway
What assessment findings are incorporated into the ABCDE primary assessment - CORRECT
ANSWER✅✅✅A - assess airway for patency
,B - assess breathing by looking for bi-lateral chest wall movement, listening for breath sounds and
feeling for chest movement
C - assess patient for circulation by checking pulse, capillary refill, colour and warmth
D - assessing patients LOC using AVPU, GCS, PEARL and pain levels
E - exposing patient from head to toe to check if there are any other injuries
Situational Awareness Definitions
- Perception
- Comprehension
- Projection - CORRECT ANSWER✅✅✅Perception: how you view things
Comprehension: how you understand the meaning
Projection: how you use what you found in the future
Factors that affect situational awareness - CORRECT ANSWER✅✅✅Stress, time pressure,
distractions, culture, fatigue
Algorithms for DRSABCD - CORRECT ANSWER✅✅✅D - Dangers
R - Response (AVPU)
S - Send for help
A - Airway
B - Breathing
C - Commence CPR
D - Defib
Secondary Survey - CORRECT ANSWER✅✅✅F - full set of obs, fluids
G - give analgesia, do they need glucose?
H - head to toe examination, history
, Management of an airway for a semiconscious person - CORRECT ANSWER✅✅✅Head tilt/chin lift,
jaw thrust, nasopharyngeal airway
Management of an airway for an unconscious person - CORRECT ANSWER✅✅✅Head tilt/chin lift,
jaw thrust, oropharyngeal airway (guedel's)
Management of an airway for an conscious person with spinal precautions - CORRECT
ANSWER✅✅✅Jaw thrust to limit spinal movements
Differentiate head tilt/chin lift and jaw thrust - CORRECT ANSWER✅✅✅Head tilt/chin lift: use two
fingers to lift chin in an upwards direction and other hand to tilt forehead back
Jaw thrust: use to hands on either side of jaw and pull upwards extending jaw out. Used in spinal
precaution patients and paediatric patients
Pulse oximetry
Indications
Advantages
Disadvantages
Limitations for Respiratory Failure 1 and 2 - CORRECT ANSWER✅✅✅Indications: to measure oxygen
saturation in patients and when using oxygen therapy to monitor effect
Advantages: cheap, easy to use, relatively reliable, non invasive, immediate readings
Disadvantages: only measures oxygen, can by inaccurate when used with nail polish or if the pt is
shivering
Limitations for Respiratory Failure 1 and 2
- useful in resp failure 1 as this type of failure causes hypoxia.
- not useful in resp failure 2 as this type of failure causes hypoxia but also hypercapnia (high CO2)
Non-rebreather Mask
Indications
Nursing Considerations - CORRECT ANSWER✅✅✅Indications: short term use in acutely unwell or
deteriorating patients
